BAKERS ISLAND - BUILDING INSPECTION (20) G« zg i667
,,�
The Comm Qf( aiiachusetts
® lent of Public Safety
Massachusetts State Bu' di C° e 0 CMR)
Building Permit Application fordi�r o�r Char►a One-or Two-Family Dwelling
(This Section For Official Use Ord )
Building Permit Number: Date Applied:. Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
jagns L's/gnd 6fxhm A� oI '
ftVtVxee1q — � ity/T�c� t ) t)0 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
1 Existing Building,, Repair❑ 1,Alterations I Addition❑ Demolition 0 (Please fill out and submit Appendix 1)
L I Change of Use ❑. Change of Occupancy Cl 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 ❑ NON
Brief Descriptiorl of Proposed Work:
�efT
F i , f'.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Buil 'ng Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): i p Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ( a aq 1 S6
Total Area(sq.4.)and Total Height(ft.) 0 C9 -7 t /
SECTION 5:USE GROUP(Check as applicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E. Educational ❑
F: Fact F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H5❑
I: Institutional I-1❑ I-2❑ I-3❑ Ill❑ M: Mercantile❑ R: Residential R-113 R-2❑ R5❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility 0 Special Use O and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 IIA 0 IIB O IIIA ❑ HIB O 1 rV 0 1 VA O VB 0
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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ re permit
i enclosed
trench or specify:
perntit is enclosed❑
Railroad right-of-w y: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Apphcablez Is Structure within airport�af proach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or N2 Yes 0 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:
The Commonwealth of Massachusetts
4& `7 Department of`Public Safety
Massachusetts State Building Code (780 CMR) r
' ' Building Permit`Application to Construct,Repair,Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes,water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done. ,
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property "Owner
oO bQGmSSL `—fLc.laf o"?q 1 uac�
Name(Print) No.and Street I •, 1
W, � iV]Pwn Zip
Property Owner Contact Information: L- .
Title Telephone No.( ) Telephone No, (cell) e-mail address
If applicable,the property owner hereby authorizes 1X-e-
Name ,Street Address t, City/Town ,, State Zip
to act on the propertV owners behalf,in all matters relative to work authorized by this budding ermit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 ca.fL of enclosed space and/or not under Construction Control then check here (and kip Section 10.1)
10.1 Registered Professional Responsible for Construction Control'" r
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'COMI'BNSATION 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 0 No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item Total Construction Cost from Item 6 =$
and Materials) ( )
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)
3.Plumbing $ G)�
4.Mechanical (HVAC) $ Note:Minimum fee=$ l.J (contact municipality)
5.Mechanical (Other) $ Enclose check payable to t 1 S 6 Lon
-
6.Total Cost $ J� (contact municipality)and write the 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 y knowledge and understanding.
Please Rnnt and sign name Title � ^A Telephone No. Date
Street Address City own State Zip
Municipal Inspector to fill out this section upon application approval: '°
- Name Date
,Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block # and Lot# fordocations for which.a street address is not
available)_
No. and Street,. City/Town - Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
e
}
r
c701 �� I -q C)c-9 fi
3
icio�
IT 9
n
s
coy ` \� ,o� �.• 5 �� , moo, 'NS
2
e