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The Commonwealth of Massachusetts
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Department of Public Saf
Massac � 3 Massachusetts State Building Code( ( N
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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` I No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2-PROPOSED WORK
Edition of NIA State C used If New Construction check here❑or check all that apply in the two rows below
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Existing Building Repair r\Iteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix l)
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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BULL ING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 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-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ D: Business ❑ E: Educational ❑
F: Facto F-t❑ F2❑ - IL• Hi h Hazard H-t❑, H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional I-I❑ 1-2❑ I-3 Cl14❑ NI: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ , S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a livable)
IA ❑ IB ❑ IIA ❑ 116 ❑ IIIA ❑ 11I11 ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal Pr A trench will not be Licensed Disposal Site
required I�or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: I Hazards to Air Navigation: UA I h to,r C„nm i,si �,I e, ,� t r xr,t:
Not Applicable is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or Na)Er I Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the buildiny,contain an Sprinkler System?: _ Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner @ ,
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Name(Print) d No.and Street City/Town Zip
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Property Owner Contact Information: ,
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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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 under Construction Control then check here O and skip Section 10.1
10.1 Registered Profe--s\sional Responsible Lf�oor Construction Control
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Name Re Listrant� Telephone No. e-mail address Registration Number I I:�S 7 �tilf nrk �� S \e vh mil$_ 19Z0
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - -
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Company Mme _
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Name ofPers'on. \\\Responsible
effor Construction License No. and Type if Applicable
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Street Address City/Town 1 � ' State Zip
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Telephone No. business Telephone No. cell a-mail address
SECTION 11:VVORRF:FS'COMPVNSAIION INSURANCT AFFIMWII' M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with-this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? - Yes Cl No O
SECTION 12:CONSTRUCTION COSTS AND PERb11T FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building 5 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
1. Plumbing $
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ l{ (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 accurate to the best of my knowledge and understanding.
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Ple.ue print.nJ sign name Title Telephone No. uc
Street Address City/Town State .�Z`i/p• Q
Municipal Inspector to fill out this section upon application approval• `�hl'✓w lam&
Name Date