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B-19-42 - 0015 BECKETT COURT - Building Permit t-f 30 M 3 g D The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Sect' Y). - on.,F.or Official Use ^ f Building Permit Number: Date Applied. Building Official: SECTION 1:LOCATION No.an Street C- /To Cod Zi Name of Building(if applicable) a s� C d Assessors Map# Block#and/or Lot # l SECTION 2 PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ Addition Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑ Is an Independent Structural Engineering Peer Review required? Y s ❑ No Brief Description of Proposed Work: —� ' SECTION 3:COMPLETE THIS SECTION IF EX TING BUILDING UNDERGOING REN ATIO ,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U. Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system required❑or trench or specify:permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport a`pprpach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or Not]," Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION f Nan 1and Address of Property Owner /OJb 5� Name(Print) No.and Street City/Town Zip Property Owner Contact Information: J Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owners behalf,in all matters relative to work authorized by this building permit application. c„ SECTION 10 CONSTRiJCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under.Construction Control then check here El. Otherwise provide construction control forms Osee section 107 in the code as required. 10.1 Registered Professional Res"onsible for Construction Control.(the rofessional coordinatin`'dowment submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contract r � a L 114 ge� �t Company Name ZY a�rz c Name o sponsible for Construction License No. and Type if Applicable v o Street Address City/Town S Le Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No 13 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ i 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ © ©p Q (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true an accura to the best of my knowledg and understanding. Plea e p ' t and sign name Title Telephone No. Date Str t Address pity/ own state Zip Email� Addr ss 57t Sljfc Municipal Inspector to fill out this section upon application approval: 4 91. Name Date