0005 FILLMORE ROAD - BPA-16-803 ROOF FOR BLDG -T e'
The Commonwealth of MassaMU916NAL SERVIC
yDepartment of Public Safety
f Massachusetts State Building Code(780 CIM PR [b A 3 3 b `
Building Permit Application for any Building other than a One-or PR
amity Dwelling
(Phis Section For Official Use Only)
Building Permit Number: Date Appb6d: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
_� I%( u.MoV1-7- 1Lo sp-yAu�-Nl MP�
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 Building❑ Repair❑ Alterati ition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an.Independent Structural Engineerin P f Review required , Yes ❑ No ❑
Brief Description of Proposed Work: / ^ �O1 O,//
%7-rF o��- j�IT14 -
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
a SECTION 6:CONSTRUCTION TYPE(Check as applicable)
- IA-0.. IB ❑ II.4 13. IIB ❑ IIIA ❑ IIIB ❑ 1 IN ❑ VA ❑ VB 13
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❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Histone Commission Review Process:
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:
I
r. SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and A P3Jress of PropertyQwner
N me(Print) —� ,No.and Street City/Town Zip
Prerty Owner C ct Information:
Title papor Y1(�g4tr Telephone No.(business) Telephone No. (cell) e-mail address
If ap licame,the roperty 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)
building is leas than 35,000 cu,ft.of enclosed s ace and or not under Construction Control then check here O and ski 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 Co tractor
Co an ame
A-s CAS - 075' to
e of Person kesponsible for C lrucpY�t Lic a No. and Type if Applicable
�d7 rant-- i)'Y�L/ C /-Ylr•'�w--
`SSttree1t Address [�',r�� �{,�(► // t—�j /� I ��...,,
le Zip
/4 ��•—C.L —,j o�S Town GY) elm
Telephone Telephone No.(business) Tel hone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 13 No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Tom'
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 $
r —_ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT �� S
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application i true and accur o the best of my knowledge and erstanding.
P�e not and sign nam y�G _ TittQ e, Telephone No. Date
Street Address Ci Town
tY/ State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date