TINKERS ISLAND - BUILDING INSPECTION (005) Cra 5 L-1 � 2 s
RECEIVED
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The Commonwealth of Mass ac usetts
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Department of Public Safe Massachusetts State Building Code(78 Q�ISIR��L 10 A % 5 1
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 I and Lot M for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Budding(if applicable) _
SECTION2.PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here Cl or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition O (Please fill out and submit Appendix 1)
Charge of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes a No ❑
Is an Independent Structural Engineering Peer Rfview required? Yes ❑ No !R
Brief Description of Proposed Work: S-.I
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): Proposed Use Group(s):
SECTION4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(.sq.ft.) I I'L I . Z
Total Area(sq.ft.)and Total Height(ft.) - 00 19 /LGjr
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Dustiness ❑ E: Educational ❑
F: Facto F-I❑ F2❑ H. High Huard H-1❑, H-2❑ -H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ 1-2❑ F3 Cl 14❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ 16 ❑ IIA ❑ 118 Cl 11 /IL\ ❑ IIIB ❑ IV ❑ 1 VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit.-jbe
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal d Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not P srequired�,or treor specify:Private X or indentily Zone: or on site system 1 permit is enclosed
Railroad right-of-way: Hazards to Air Navigation: �L-\!"liao�ic ....... I'nwts:
Not ApplicableA Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No fK Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of CMIa: Use Group(s): Type of Construction: ' Occupant Load per Floor:
Does the building 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) No.and Street City/T wn Zip
Property Owner Contact Information:
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Title Telephonene in elephone No.(busess) Telephone No. (cell) —t R 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 budding 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 0 and ski Section 10.1
101 Registered Professional Responsible for Construction Control
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(�ilille Re 'A rant) _r n TelephoneNo. e-nail address � Re•fs anon NumbEF r *le'
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - -
Company Name
Name of Person Responsible fur Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:VVORRF:RS'C0N1VFNSATtoN INSURANCE AFFILMVII' 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 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Budding $ BO. 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 : $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDINGPERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurst•t e b st ml knowledge and understanding.
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Please nR_'t} pod n game Title V4-dephune i �. Date
Street Address �' Cily/Town State Zip V
Municipal Inspector to fill out this section upon application approval:
Name Date
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