BP-47474'SECTIONS ijNSTRI)i SERVICES ,
31 Li nsetlC 1 st S pervisoo N IAppfrable 0
Licensed Consul Sigma Lew ceNumbar
Address Expimfion Oate:
51 nature'. Telephone:
-SECNDN¢�ygR�gS.CO4IPENSA'RON INSOR'RNCEAFFIrGaTiMAGALCUsil
Workers Compensation Insurance AlAaavtl must ba completed and submitted with Has applies Failure th pmNae this
affidavit will result in the denial of the issuance Of Me building porn (MGL 152 Section SEA),
Signed Affidavit Attached. OVEs ONo
h,:,m..,"A;ASSSdIh5 OESGRYPEOHi{}FfR41PO5EGq'.ONIb Qbeckall applicable)
O New ushemgion 0 All 0Roper, 0Amel Bu ing(reconvene)
oa'retaanysEn. M owmnlmm 0slOo 0 Femberinumn ii,dricsomr,
o Wwas Cam
-*'bY 35FOi DN G-PROPQ$i9 PROJEG4'BSE'.rJNCWGINGTfjgEEFA(A1CV'OKMOREANd.IXENPY0SE9 �?�v+.v
Ibe following tlesnstrea n; are eased on Me Mn aCuse SOM Seasonal BM Prefer, Coca Article 3, as not .. See Me Come.
final restaurant, lounge, Healer, useful, etc Case Code Section3030)
Dessi:
O Bus loess-aRce assembly wed less then 50 o¢upeMs- Indicate Medical or other pmf ss anal (see Cotle Section Sclul
O Education - sanction for training reasoning Build day care for Hose over 2 year months (see Cede Section 305.0)
o FaGay/IntlusMal (see Code Section 306.0)
G Men Rout (see Code Seclion 3070)
o Institutional � hapstal, curving bone infant day care (see Code SeNon 308 e
O Maborm le -retail metes (see Code Section 3090)
o Residential - three 0r more family, hotel how Code Section 310.0)
O Storageincludinggarage (sea Code 3110)
O Johly B Miscellaneous Number -indudesGross and agricultural Carefu es (seer Cede Seems 312.0)
O New Tenant - far any of M1e above, please indicate (sae Code Section 1100 and Zoning Seri Section 35)
OTentor Trailer -temporary
Purposes
O Other
De lobe Me wapssal bmi INCWOE number of dwelling units and bedrooms of occupant lead as applicable, also existing
ConfiYm(if eMa space is needed, Mai an additional sheet] _
+S wt�e�"1�PNl TYPEOP CPNSTR CMDN.WSWflALFYOD 9�1iF412k1E[E 9x' � :::%.
0 New conntructmindl Additional (total gobit feet porposed) indeed -
If the project is an rid Gon to existing sl 1 re-togg gross square feet of emshng
OAnemnoncle st g no lesions in gross square feetq separate Refuse DhapporrielCombustion-mequ red
Will this protest be subject to CONSTRUCTION CONTROL (am 35,000 on It) Oyes El
If yes, see Cale Seelidn 116.0 Designer to amenit Cale Synopsis in additional to original Plans.
Will this project require Peer Review (over 400,000 cuff) Oyes O No (see 1250 Code& Accurate l)
APPLICANT TO PROVIDE PEER RENEW AT THEIR EXPENSE. SEE ]80 CMR
o Demoiisn' msumes4ucwre:
D Mwmg'-(prwlde any of DPW moving limmend
Type of stm sure: from where Mal or aaferess):
W where deal or hiddrims) number 0"ailing u n hg:
umber of bedrooms per dwelling one
D Replacement doers and wndows-(for exlAing only) (only where doom and windows exist and will root be enlarged) EGRESS
dimensions must he maintained, EniaMWndowsinanexiAngdllingwilbidereylasanalterabon,lhemisewlI
be'mcutled'n new construchurn (see Circle yormon 300321 br residential and Aucle 10 for musbap.
O Temporary s0utlure-intluders, when allowed, money, tads and Me like and only Wr Pared Will sn''time. Besvhe:
-; �EOIfON&-MECHANICAG$'PpI61A1t,YF0EL �::_:
o Furnace (hmaid fuel gas(OeNtal or pmpa ), fuel sh elecidc'ay. Other( mini
D Bdlef ig eming)-fuel gas hamml a pmpme), fuel oil, assembly other Decal
• Al (combined unit) - primary fuel, natural gas, propane Se@icdy, other (sootily):
O An Wnditioning-(se mle unit)
D None of Me above to be rumored
D Hot Water Gas Electric Fel Og Other
_-...$EQjION9�spRINKLP�$�NDLP�WREPRD#CT16x �y,^�a „��y
DRequired, iipprovided plans not provided, why?
D Not required, not to be lnstaletl, Why?
-e§ECTION tO-NEOtDINEOO STREEFF�'RKING N[Znnin !erldAmbl ACedi9, ^E X„'-�i
O Parking plan submined to. Building Dept_ Planning Boom_ Dale submingd_
Number of spews Indoors mail Torgirmvifia
Handicap Spaces - proffed yes _he_ Ifyes, how number as a pad ofther toMl reequired numbs_
Is Route 6(Slee Road) ¢Mane permit required? yes no_ it yes, has it Men goal loss no
Submit copy of application and/or permit as soon as available.
_ nSISCIDON IllIDEx ATION _ x)s
3 .� • e ^a/
11.1 AmhlMa En9lnm for Il remain
Company Name'
Address:
Phorw#:
Codified by Shifts of Massachusetts as:
Cembecaeon Number:
NoneSimwGl stair may ou all Aans a am viLS B Oman tlocamenfs SHALL BE currents; and nook Rpmdeeiom..
112A hiWWEngirreer - project supemN on and repot
Company Name:
Address:
?bane in
Counter by State N Massachusetts as:
Cedifcat Number:
tabl: SomMuss and seals on Rll clans afieav LSBoher normal SHALL BE ororms and ne(Mpr uel s
113 GMaml Committee n n
Company Name y ill Ci
Address:
Phone A. Jost I
Carefuctlon Supervisors License Number: LZ
We. Signatures and seals On all alms affidavits e other documents SHALL BE originals ant M&ropmtlncrme.
e
-SECTION
1Z-ESTIMXTEUCONSTRUOT Oftw$y
film
forest Cast (it) W be wmlelent by Robote
Meant
1, Building
2, Electoral
3. Plumbing
k Mushenlcal(HVAC)
5, Off BIRet Parkin
6, Total (1 21314e5)
Emerged ToUl Cost lncludin Labor'.$
SECTONt3A QWNERANTHORhAmjQN
-AVtnb¢Nlpplefetl
J{iY§1(pWntlha Ydo4 asector bull
rs applves(onIN ermi
(Plea Print
I.
sew er of the subjscl pmpery hereby anMonea
to nmy bah If, ins a
rel56vemwoM1an read by this bi pennd apprctimem
SECTON I3B-:OWNERIAOTHORIZED AGENT DECLARATION -:
1
as Owned ho M ant hereby denlare Mat me statements
and hernial
on theforegnin8 application are free
and accrued WMe best of of mu ge and belief
',..
Signs tl un the pains an penalties olperjury.
�I
8'naNR Of Own elTa rixetlA
" $E$TION IA'INSPECTORSREVIEW(DOMMggill
' 1, HOLD reason:
Dale:
2, HOLD subject W Zoning brand efAppeals
Armen
Date:
3. Comments:
a Commentsr
-.
s. InapeclOts Signal re:
Date: AP 1
7 20D7
-BE IOR"APGLIDANTN4TIHCATI
Applicant informed ofahove
qp Q Time f1cCI
Comments
_
norm16-OFP(OENNSPECTORS NOTIRS
--"
Less Applice6on Fee $25,B)
Remaining Balance
$150
Total Permb Fee:$
Offer $ Amount is
TOTAL FEE: so" J
Gross Area- New Construction tINal sq. ft.
Gross Area Alteraton halal sq.R,
Pend Issued to
�- n�
yai
a A J
CONNUUMU