26, 28, 30, 32 CELESTIAL WAY - BUILDING PERMIT APP The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CAR)
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:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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o.m6 Str6et 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±1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No G?�
Ism Independent Structural Engine ' eer Review required? Yes ❑ No
Brief Desorption of Pro ed os W rk:
J l
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): I 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
—T.—Factory F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M.
Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R�❑ +
S: Storage S-1❑ S2❑ U. Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ "-`IIIA-❑——111B-O 1 IV ❑ VA ❑ VB O -
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:
A trench will not be Licensed Disposal Site❑
Public
❑ Check if outside Flood Zone❑ Indicatemicipol-❑ required❑or trench or specify:
Private[Ior indentify Zone: or on site system❑
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ 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
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Name(Print) No.and Street
A City/Town Zip
Property Owner Contact Information: f/// n
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 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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ame egistrant) 71/�S Tele hone No. e-mail add 7` Registration Number /
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S eet Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name Of
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
_ SECTION 11: (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 _ , 00
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)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ ��' - /00 (contact municipality)and write check number e
SECTION 3: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.
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Please riot and sign n e Title T ep No.
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Street Address City/Town S e
Municipal Inspector to fill out this section upon application approval:
Name Date