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B-17-938 - 0041 VALIANT WAY - Building Permit The Commonwealth of Massachusetts Department of Public Safefir Massachusetts State Building Code( P 21 P 10 W Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied Building Official: v SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) 1 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 _RepairRI Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) 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? Yes ❑ No ❑ Brief Description of Proposed Work: d-0 •p+►-y 9 Put to sr i AJ 61— rx SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,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.) d( 1400 /b On Total Area(sq.ft.)and Total Height(ft.) OU �(, �7.V `t, SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ 5❑ B: Business ❑ E: Educational ❑A- F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R- R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA V IB ❑ IIA ❑ IIB ❑ IIIA ❑ II0 ❑ W ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site Public§( Check if outside Flood Zone Indicate municipal Private❑ or indentify Zone: or on site system required)Kor 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 approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or N Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 9Y1�►�� T13 G , C : SECTION 9: PROPERTY OWNER AUTHORIZATION Name'and Address of Property Owner Name(Print) ee City/Town Zip Property Owner Contact InfoL�tion: Title Telephone No.(business) Telephone No. (cell) e-m 1 address If Z licable,the Mperty owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check her and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State 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? Yesgj No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE-.. Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ �; bPfy Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ l j500 appropriate municipal factor)_$ 3.Plumbing $ aPl 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipali ) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ (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 and accurate to the best o my knowledge and understanding. P eWipk and si n e ..... Titl Telephone No. Date 01107 Street Address City/Town State Zip Municipal'•Irispector to fill out this section upon application approval: V 4T✓'A / [ �"�j/ rr a Date I � • I I wl�j3: oil?+7 1 \ DW o I " W 3r� ,135C.33 �' • M4G o GWK I fj Ae� v'/;%I�24 L7 1-1.� IrF 12ok qo 15 oqE—Ft"A11G -- `- 27,E • ,:• G o U ni'4'F;.K,T c�it ,I ._.___- 3 ALL DIMENSIONS AND ® DESIGN PLANS ARE PROVIDED FOR THE F GNED FOR / .;�y4 BY DATE BY SCALE DWG SIZE DESIGNATIONS FAIR USE BY THE CLIENT OR HIS AGENT IN G I rJ t;+�,r R vN `' ! NO. GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED WITHIN- r VERIFICATION ON JOB THIS CONTRACT.DESIGN PLANS REMAIN THE � SITE AND ADJUSTMENT PROPERTY OF THIS FIRM AND CAN NOT BE TO FIT JOB CONDITIONS. National Kitchen& Bath Association USED OR REUSED WITHOUT PERMISSION. =s r At I/ It N k r LL , , _ r ` r q2„ ALL DIMENSIONS AND DESIGN PLANS ARE PROVIDED FOR THE DESIGNED FOR BY DATE BY SCALE DWG SIZE DESIGNATIONS FAIR USE BY THE CLIENT OR HIS AGENT IN f� } DW �' 1 REV _ ' NO. GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED WITHIN — / �t ©o � �� I V VERIFICATION ON JOB F- 1 THIS CONTRACT.DESIGN PLANS REMAIN THE Z SITE AND ADJUSTMENT PROPERTY OF THIS FIRM AND CAN NOT BE TO FIT JOB CONDITIONS. National Kitchen &Bath Association USED OR REUSED WITHOUT PERMISSION. �ro � • x $b �a.i�t�'�' ' „, ...fin zM � ;.� "� .. .n .. _ � f+