5 BURNSIDE ST - BPA-12-353 3 The Commonwealth of Massachusetts
Department of Public Safety
4 Massachusetts State Building Code(780 CMR)
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
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SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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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 Build big Al Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ;R 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 Descriptio
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(of Proposed Work:
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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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ Awl❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-I❑
S: Storage_S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:---�- ----
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ 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:
Licensed Disposal Site❑
Public El Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentff}'Zone required❑or trench or specify:or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I Inl ri Cu_mnu si..n Rce_ii u I r o.,.es:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ 1 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION t
[Name and Adc 4,ss of Pro arty Owner
a m 1016 4-
Name(Print) No.and Street Ct� Zip
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Property Owner Contact Information:
IMY
Title Telephone No. (business) Telephone No. (cell) e-mail address Y'
If applicable, the property owner hereby authorizes 4�
Y
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 tinder Construction Control then check here❑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
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Company Name
Name of PgeNon Respo isible for Construction City/ own State License No. and Type if Ap livable
Street Address Zip
Telephone No. business Tele hone No. cell e-mail address
SECTION 11:11U1'KFNS'CUNI7 FNSA'HON INSUK ANC'AI+IPAVI'r 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building - $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4. Mechanical (HVAC) $ Note: Minimum.fee=$ (contact municipality)
l 5.Mechanical Other $ Enclose check able to
KJ 6.Total Cost $ O c9(� municipality)(Q (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. curate to the best of my knowledge and derstanding. --
Please prt uu1 sign T" Telephone No. Date
ne
Street Address City own State Zip
Municipal Inspector to fill out this section upon application approval: /o o,
Name Date