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B-17-1025 - 0052 VALIANT WAY - Building Permit To,6� The Commonwealth.of.Massachusetts i ` Department of Public Safety Massachusetts State Building ( �780 Code CMR Q 1 1'Q C- ,I l A Building Permit Application for!any Building other than a One or Two-Family Dwelling (This Section For Official Use Only) V' Building Permit Number: Date Applied: Building Official: NSECTION 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) �. 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 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 Engine • Peer'Review required? Yes ❑ _No� Brief Description of Pro osed Work: �.�I.AcFL,AU &A t S'r `,�J 6- W 1�Do u� W t'1 H 41 k c i"© )d v L t40,J :' D 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.) U001, Total Area(sq.ft.)and Total Height(ft.) S60Z? 49, 01 .3600 ,2 0 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal: Water Supply: . Flood Zone Information: Sewage Disposal: Trench Permit: - 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;4or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 01 Is Structure within airport approach area. Is their review completed? or Consent to Build enclosed❑ Yes❑ ik No 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?: A119 Special Stipulations: 1012-1 r•1NtL-,1E0 T(--.> G .C- SECTION 9: PROPERTY OWNER AUTHORIZATION �Na e and,Address oProperty Owner Name(P int) o. d Street City/Town Zip Pr perty Owner Contact I orma ' : Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the p operty owner hereby authorizes 'r 14 AA.) ®LA) �S I�C k`�A 1JD S��io Aj P s�o ii qA- a i 10.7 Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 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 ZT up,&J -a Company Name D 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 AFFIDAVrr(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? Yeso No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 5-3 3 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 $ S "'� (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 of my knowledge and understanding. .;HAW Pa.j a ��;fz�cT� �- 7 6 9 !7 Please print and sign name Title Telephone No. Date J t AjoGt�-AAJD Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: . P P P PP Name Date t