26 1-2 HANCOCK - BUILDING INSPECTION CIO
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
cQJUlf Building Permit Application for any Building other than a One-or Two-Family Dwelling
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T s ection For,OfficiatUie
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Building Permit Num er '77"
SECTION'1:LOCATION(Please indicate Block*and Lot*for locations f6r'which a street addtess.is not available)-- ,
No.and Street City/Town Zip Code Name of Budding(if applicable)
Edition of MA State Code used- If New Construction check here 0 or check all that apply in the two rows below
Existing Building U/1 Repair 11 Alteration 0 1 AdditionO I Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 1 Change of Occupancy 0 Other 0 Specify: Qe P/a L' e A+y b 7— b-1 i 1U c),C".)S-
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 Nome
Is an Independent Structural Engineen. Pw required? Yes 0 No
Brief Description of Proposed Work: n� eer Review
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SECTION 3:COMPLETE THIS SECTION IF,EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANdE'IN likoR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s),
SECTIONA: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 0 A-2 0 Nightclub 0 A-3 0. —A-4-0 A-5 0—F B: Business 0 E: id.cation—alD
F: Facto F-I 0 F2 1:1 1 ..IL I!IHazarcl H-1 EJ H-2 13 H-3 0 H4 0 H-5 0
I: Institutional 1-10 1-20 1-3 0 1-4 C3 Mercantile 0 R: Residential R-10, R-2 11 R-3 0 R-4 0
S: Storage S-1 0 S-20 U: utility C3 Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION-TYPE (Check as
IA 0 IB 0 IIA 0 IIB 13 IIIA 0 IIIB 0 IV [3 VA 0 VB 0
SECTION 7:SITE INFORMATION (refer to,780.CMR 111.0 for d0taflg on each,ite'm)'
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 13 Indicate municipal 13 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone:— or on site system 13 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Pnvess.
Not Applicable 0 is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed El Yes [] or No 0 Yes 0 No 0
• 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:'PROPERTYOWNERAUTHQRIZATION �p �.�+,ti� __ '� � '�^`%
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
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 7
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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.
an' SECTION 10:CONSTRUCTION CONTROL`(Please fill out Appendix 2) ' :? .
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'(If buildin 1s less than 35,000 cu.ft.of enclosed! ace and%o"r not under Construction Control ther=check fiere�C7 and;ski -Section 10:1
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10:1 Registered Professional Res'�Qnerble for-Constrnchon Control rs.
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Name((Registrant) Telephone No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
�,10.2 GeneralContractor'=
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address sty/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
- -1SECTION 11:.WORKER5COMPENSATION INSUPAANCEAFFIDAVIT MGXL e:152.: 25C6 '- -
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 ispuance of the building permit.
Is a signed Affidavit submitted with this application? Yes BY No ❑
_'" • ` _ SECTION-11'CONSTRUCTIOMCOSTS AND PERMIT FEE ,.
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ a
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 $ 08 ob (contact municipality)and write check number here
SECTION 13E-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 print and sign name Title Telephone No. Date
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Street Address City/Town !� State i q
Municipal Inspector to fill out this,section upon appll ''' J
. , . ' ication approva- Dat Name:' e.