0008 1/2 ALLEN ST - BPA-13-77 ROOFING INSpECTIOKALY qQmonwealth of Massachusetts
W
`Department of Public Safety
`:1016 p p M:sssachuseltsStatc Building Code(780CMR)
Building�l ernJA jp)ic1h8kor any Building other than a One-or Two-Family Dwelling
-19 .(Mis Section For Official Use Only)
Budding Permit Number. Date Applkd: Building Official:
^� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addrW is not available)
� `6& ALLSWSt. S „aIEwt Ma 01470
�Q 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 ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Cl Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Now
Is an Independent Structural Engineering Peer Review reyuireJ? Yes ❑ �
No -
Brief Description of Proposed Work:. f-S�
PEAm-
SECTION 3:COMPLETE TIIIS 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 UseGroup(s): - - Proposed UseGroup(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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-t❑ F2❑ If: High Hazard H-1 O. H-2❑ . H-3 ❑ H-4❑ H-5❑
C Institutional f-I O 1-2 C3 1-3 0 I- ❑ M: Mercantile❑ 7R, Residential R-1 R-20 R-
3 0 R-4❑
S: Storage S-t ❑ S-2❑ U: Utility❑ Special Use O and Please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA IBO IIA ❑ IIB ❑ Ille\ ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Hood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Cl Check Check if outside Flood Zone Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required O or trench or specify:
Private❑ or indenlify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: I{\11i_95gjr
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ Yes O or 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?: _ Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
(�)Oe H amiC 1�1 Mae o�ia - r �fa1 'otdl .){ e►� , . OIgG O
,a
Name(Print) No.a d Street - Cily/.To`rtvn .) t t 'f Zip S
Property Owner Contact Information: J t
- ,�;°e_•t � ff a ��2�e�Via,vlce�V a1�1'ao.
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 act on the property owner's behalf,in all matters relative to work authorized by this building permit a lication..
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,600 cu.ft.of enclosed space and/or not under Construction Control then check huejQ 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
L;or. SeN%cQs rmw c- (nalvv rz 2�w�
Name of Person Responsible for onstruction License No. and Type if Applicable
tnC-bcwia 1 1-w,
Street Address City/ wn State Zip .
�_�- 01 _-_ �?ay�y��. r I:nn-S'er�i cC• coM
Telephone No. business Telephone No. cellil address
SECTION 11:FVORKER.S'COXIIIENSA'FION INSURANCI.AFF'IIMVrl' 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 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $ Oa Building Permit Fee—Total Construction Cost x_(Insert here
2. Electrical $ :appropriate municipal factor)=$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici�pylalily)h
5. Mechanical Other 6 Encluse check a able to �// �l/ 6
PY
6.Total Cost $ (mntad munici ali )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains a nd penalties of perjury that all of the information contained in this
application is tree.red accurst to the best my knowledge and understanding.T • Lav R-8 oY- In 17_9 b
Please print and sign Arne Tit Telephone No. ate
11 M(00, naNt 01
Street Address city/Towd State Zip ?
Municipal Inspector to fill out this section upon application approval: *rw
Name Dat I