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BP-66083y �:._ a w. ... SECTION 3',- C©NSTRUCT.,ION: SERVICES , 3.1 Licensed Construction Supervisor. Not Applicable ❑ ❑ Demolition* - describe structure: License Number. ❑ Trench Permit Required? ❑ Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq. Address: Signatur Expiration Date: M4$ � ( ❑ Moving* -(provide copy of DPW moving license) Telephone:,F -YS� o m ;:. ` �... GTION,- W©R}CI=R S CGIMP.EN5AT1 ON 1NSURANCE AFFIDAVIT,. MGL o 152„ 25 g § }, Type of structure: e - from where (map/lot or address): Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provithis to where (map/lot or address): number of dwelling units: number of bedrooms per dwellin unit: P dwelling affidavit will resulfin the denial of the issuance of the building permit (MGL 152 Section 25A). Signed Affidavit Attached: es ❑ No ❑ Replacement doors and windows - for existing g only) (only where doors and windows exist and will not be enlarged) EGRESS dimensions must be maintained. �.c � .. ..., .. ;; .., �EC.TION 5 --DEC ` .. , � .. ,.. _.. S R RT1ON P.PRbP,C51=U.WOR {Check 1,applicabl . ,• . . ❑ New Construction ❑ Addition ❑ Repairs ❑ Accessory Building (Shed/Garage/Other) ❑ Temporary' structureand uses - includes, when allowed new tenants, trailers, tents and the like and only for limited periods of time. Describe: ❑Other (Specify Sec. 6) ❑ Demolition ❑Si9n ❑ Replacement window/door ,� .1.. � ..� ❑ Fire Protection No, of Windows Doors .� ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): - ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other(specify): -:PROP©5ED'PROJEC'"USE:= IN CLU13[NG TNRE FAMILYR,MORE.ANDEXEMAT;USES '. ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ty) The following descriptions are based on the Massachusetts State Building 8th Edition, Code Article 3 as no noted. See the Code. ' ❑Air conditioning - (separate unit} Roof Top Unit RTU New ❑ Replacement ( ) p cement ❑ ❑ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0) 11 None of the above to be provided Mechanical Ventilation ❑ Describe: ❑ Hot Water: Gas Electric Fuel Oil Other ❑ Business - office, assemblywith less then 50 occupants -indicate Medical or other professional se p (see Code Section 304.00 Education - struction for training including child day care for those overt. 9 months (see , u SECT#ON,.9 - SPRINF LI RS AND/OR I[R E PROTECTIONS C0P#ES.f3F PLANS AIVD=NARRATIVE REQUIRED., year Code Section 305.0) ❑ Factory/Industrial (see Code Section 306.0) ❑ Required: plans provided plans not provided, why? ❑ High Hazard (see Code Section 307.0) ❑ Not required, not to be installed, why?" ❑ Institutional -hospital, nursing home, infant daycare (see Code Section 308.0) Narrative Submitted? ❑Yes ❑ No ❑ Mercantile -retail stores (see Code Section on 309.0) TIC7N(i ..IDENTt. t ❑ Residential - three or more family, hotel (see Code Section 310.0) 11.1 ArchitectlEngineer - for overall design ❑ Storage - including garage (see Code 311.0) Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0) Company Name: ❑ New Tenant - for any of the above, please indicate (see Code Section 105.1) Address: ❑ Trailer - temporary Phone #: Purpose? Certified by State of Massachusetts as: ❑ Other. Certification Number: Describe the proposal, INCLUDE number of dwellingunits and b bedrooms or occupant load as applicable, also existing Note: Signatures and 9 seals on all plans. affidavits &other documents SHALL. BE originals and not reproductions. cglrfdition (if extra space is needed, attac an additi al sheet):, 11.2 Architect/Engineer- project supervision and reports Company Name: Address: Phone #: Certified by State of Massachusetts as: ` .. .°:. ..:,S.,SEGTION 7 ;TYPI OF GONSTRUCTiPN OR,WORK " 6:13 ERFORMED -= Certification Number. .,m .,. ❑ New construction and/or Additional (total gross cubic feet proposed) -indicate Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions. If.the project is an addition to existing structure - total gross square feet of existing: 11.3 General Contractor ❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required. _ Company Name: ,rQ�j �/ �,C ✓r�a',�,1t�� Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ Yes ❑ No Address: If Yes, see Code Section 107.6.2 Designer to submit Code Synopsis in additional to original plans and if existing building Chapter 34. Phone #:G�J Construction Supervisors License Number. Note: Signatures and seals on all plans, affidavits & other documents SHALL E originals and not, reproductions. Page t Page 3 (Pleaseprint). as Owner of the subject property hereby authorize �1 �i�-n asf� yr /��.•�� `� t act on my behalf, to all matters relative to work authorized by this building permit application %y--� Z - Signature of Owner Date I,r�,C :Jja as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �. Signature of wne>'lAuthorized Agent Dat Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area Alteration total sq. ft. Permit Issued to: Page 4 Location of Page 1 Debris Removal per MGL G.40 Soo. 54 -CJF 7� Revised 10/11