4 BENGAL LN - BPA-12-1047 SLIDING PATIO DOORS e
The Commonwealth Of Ittassachusetts
Y
Department of Public Safety
.\Iowa,ll u,cl is till le It Li ild ing Code(780 C.\IR)
Building Permit Application for any Building other than a One-ur T% o-
(Ibis Sccliun For Official Use Unly)
Ihtildiog Permit Number: _ _ Dale Applied: _ Building Official:
SECTION 1: LOC\'iION(t'lease indicate Block N and Lot N fur locations fur which a street addres is not available)
6
No. Mod Street City;1'ownl Zip Code Name of Building(if
SEC`FION 2:PROPOSED WORK
Edition of MA Stale CGale used It New Construction check here❑or check all that apply in the two rows below --
E\isliug Ifuildill ❑ Repair Alteration ❑ -':Addition❑ Dcnndition ❑ (Please till out and submit:\ppondix 1)
Change of Use ❑ Chanc of Occui;, ,utcy, ❑ Other ❑ Specify:.----
Arc building plans and/ur runxtntctiun d.x unwnls being supplied as part of this permit application? Yes ❑ No O
Is an hnlc1. it 1,Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed W, k:.-,--_
SECTION 3:CONIPLETE THIS,SECTION IF EXIs"rING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY -
Check here it an Existing Building Investigation and Evaluation is enclosed (Sce 780 C\IR. 4) ❑
E\isting Use Gruup(s): . ----'— — Proposed Use
SECTION 4:BUILDING MIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)t4 Area Per Flour(sq. ft.)
Total :\rca(so,. ft.)and Total Height(ft,)
SECTION 5: USE GROUP(Check as a licabie)
A: Assembly A-I ❑ A-'_❑ Nightclub ❑ A-1 ❑ A-4 ❑ A-i❑ F B: Business ❑ T;: [educational ❑
F: facto F-1 ❑ 1'2❑ IL High Hazard 11.1 ❑ H-2❑ H-3 ❑ 11-4❑ FI-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-1❑ 1-4❑ 1 NI: Mercantile❑ R: Residential R-113 R-2❑ R-t❑ 11-4 ❑
S: Storage S-1 ❑ S-_'❑ IU: Utility❑ Special Use❑.md please describe bcluw�
Special Use
SEC LION 6:CONSTRUCTION 1'YPF(Check as applicable)
IAA Ill ❑ IIA ❑ IIB ❑ IIIA0, IIIB ❑ IV ❑ I VA ❑ VII ❑
SI(CTION 7: SPIT INFORMAHON(refer to 780 CMR 11 L0 for details on each item)
Water Supply: Flood lone Information: Sewage Disposal: french Permit Uehris Iteuurval: -
-
I'ublic❑ Chock it nutside I:1oo.I Lnne❑ Indicate nmnicipal ❑ A Ircnch will not be I.it vllwd Di,posal ;it,,❑
Pric.+te❑ 0r indeiility Zones I rim site s% tvoi ❑ n•quirrJ ❑or trvnch or.prc11% _
pernul is enc loscd ❑
I :. `Railroad right-m-way: Hazards Ill Air.N:wigation:
.N
'.1 .\pphrahly❑ Iv tilru,uuo.,thin ,tirp,,It appma,h .ire, Is dice rrc icw,on11,10od'
or Cun,out to Mudd rn,I...r,1 ❑
1 cs❑ „r.VoO lr,❑ .No O
Sl:( I[ON 8:CON I7:1, 7'()F('eat HFIC-A 11:OF OCCUPANCY
I diw,n :,t Galc ( ,r(;roupi,) I C:•n.I N,n,•n: IS,uPant I ood prr lbnr
L1),,,-, the hnild in);,,'ntam.m �pmlkl,r tit,Irm` tiprc i•d'4I it'll la li,m,
r r
r
- SL_CI[ON '): PROP] It IY(AVNF_RAUII I(11(I'ZAI ION____-_
nuv and vidress ul 1'n,l,vil\'Ow nc r Y70
�rY c 1-/y�rT'r S_ _�_ mil_ L4v►� --- 5__4>A-_ (j- _--- ..
Nance (Print)
Nn. and til6l'et City/,fawn - _-- Lip
Property Owner Ctnttaet Information:
C�, nrr 141
_
I ill' -- ------ fel'phone No. (business) T'lephone No. (cell) '-mail address
If applicable, the properly owner herebv authorizes
— —
Nante Street Address City/Town State Lip
to act on the property owner's behalf, in all m,itters rclativ''it)%%orit aulhorized bIr^[his building ,criitit o ,tlication't.7'
SECTION 10:CONS"I'RUCI ION CONTROL(Piease fill out Appendix 2)
If building is toss than 35,000 cu. fti of enclus'd s ace and or nut under Construction Control then check here D and skip Section 10.12
10,1 Registered Professional Responsible for Construction Control .
t /(f d' o
Nam ��f� iBd felep`o it address —� Registration Nuntbcrrd/l� /
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor _
IQIlf,Qid , ,
Company Nance , , r l ..., •.. , a?'
Qonald W/rch(rvl / 33 �{/lr -7LI,3 _ --
Name of Person Responsible for Construction License No. and Type if Applicable
12 0jq- 0/ N 0
Street Address City own State Zip
-g•7,Y- 53 2-a 3 L�?,- - ------
Telephone No. business Telephone No. (cell e-mail.ddress
SECTION11:tt, tl,t.1'.f,.tyuIN:"gtit,Ni.y-•tn;.\.MI Alln .�I, M.G.L.c. 152. 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial ACCidents must be cumpletcd and
submitted with this IpPlicItiOn. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this a lication? Yes❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cult(from Item 6) '5---
I. Building 5 M 6,71 Building Permit Fee'Total Constriction Cost It_(Insert here
2, Electrical S appropriate municipal factor) -5
1 Plumbing $ cunt iP"t'.2
'ci ,alitt
I. \IcChoniCal (FIV:\C) 5 Note \lininnun (ce'S--( l/xl
5. \Iecllauic,tl Other 5 Enclose rIivtk payable to
i,. Total Gist 51� 6 (contact inuniCip,tlov)and write,heck it ne
SECTION 11 SIGNAFURE OF BUILDING PERMIT APPLICANT
It% cnterinl; my tiara'below, I hereby attest under the pains and penalties of perjury that all of the iofornation Cont.iined in this
application is iru'and iLLurate to the cst If nip r knots) •,I ;e and understandin ,.
- �I
--�i Y6 6
I lease pritit anti sign name I ills I Icl,hone \n. l)ah• -
/36 M/9- 017-1,2L
�Inri \ddrrss C v; Town ;t,ltc
\lunicipal Inspedur to fill out this<ection upon application approval: .._ . _ .
i ..\'ante