0207 HIGHLAND AVENUE - BPA-15-388 CCU The Commonwealth of Massachusetts
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Department of Public Safety
kfassachuselts State Building Code(780CMR)
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:
J ) SECTION 1:LOCATION(Please indicate Block q and Lot k for locations for which a sheet address is not available)
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^ No.and Street City/Town Zip Code Name of Budding(if applicable)
(1��1 SECTION 1 PROPOSED WORK
Edition of MA State Code used_ If New Construction cheek here❑or check a8 that apply in the two rows below
Existing Building F� j Repair❑ Alteration Addition❑ 1 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 W
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0`
Brief Description of Proposed Work: kp_lo(pe N wi/V/law-C �s4Hr 5>ryo
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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) 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.) Iboai
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 ClA-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ If: High Hazard H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑
t Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile Cl R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U. Utility O 1 Special Us&?ilind please describe below:
Special Use: )!:&6D p P kW
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill IIA ❑ fill ❑ IIIA 0 I1111 ❑ IV ❑ VA Cl VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 far details on each item)
water Supp1 : 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 CI or trench or speciffpermit is enclosed❑
Railroad right-uf-way: Hazards to Air Navigation: it i.tgri.__,�mrii54inn_It,"wg..l'nzc.0
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): type of Cunstructimc. Occupant Load per Hmv:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9., PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Torun Zip
Property Owner Contact Information:
7- 3Y0 320
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/Torun 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 Professional Responsible for Construction Control
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Name(Re islrant) T•le hone No. a-mail address Registration Number Le/d-
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
_ Company Nam
O
CA�Z[_ �1� G -o� 6 y3
Name of Person Responsible onstruction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:rVORi«:IS COMPENSATION INSURANCE A FIDAVII' 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 budding permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building 1 S Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ '1 P OG (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.
Please print a�i sign name Title Telephone l . Date
(13 L,p,AU S� sk1Pz. tGl o� 0/00
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approvah
Name Date