BP-25071COMMERCIAL 2002
SECTION 3 - CONSTRUCTIO Y SERVICES
11 Licensed Construction Supervisor:
Not Applicable ❑
Name of Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT MGLC 152 § 52
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result. in_ihe denial of the issuance of the building permit (MGL 152 Section 25A) Signed Affidavit Attached: ❑ yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK check all applicable)
❑ new construction ❑ addition ❑ alteration ❑ repairs ❑ accessory bldg. (shed/garage)
❑ other (specify Sec. 6): ❑ demolition ❑ sign ❑ replacement window/door no. of windows doors
SECTION 6 - PROPOSED PROJECT/USE - INCLUDING THREE FANHLY OR MORE AND EXEMPT USES
The fullon,ing descriptions are based on the Massachusetts State Building 6th Edition, Code Article 3, as noted. See the Code -
❑ Assembly - restaurant, lounge, theater, school, etc. (see, Code Section 302.0)
Describe:
❑ Business - office, assembly with less than 50 occupants- indicate Medical or other professional (see Code Section 303.00)
❑ Education - structure for training including child day care for those over 2 years 9 months (see Code Section 304.0)
❑ Factory l Industrial (see Code Section 305.0)
El High Hazard - (see Code Section 306.0)
❑ Institutional - hospital, nursinghome,infant day care (see CodeSection 307.0)
11 Mercantile - retail stores (see Code Section 308.0)
❑ Residential - three ormore family, hotel (see Code Section 309.0)
❑ Storage - includesgarage (see Code Section 309.0)
❑ U ility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
ew Tenant - for any of the above, please indicate (see Code Section 119.0 and Zoning By -Law Section 35)
❑ Tent or Trailer - temporary
purpose?
o Other:
Describe the proposal briefly, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
con ' n tra s is�, attach an additional sheet):
SECTION - 7 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
❑ New Construction and/or Addition (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.)` ❑ yes ❑ no
If yes, sec: Code Section 116.0. Designer to submit Code Synopsis in addition to original plans.
Will this project require Peer Review (over 400,000 cu. ft.) ❑ yes ❑ no (see i 10.1 Code & Appendix I)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE'780 CDIR.
❑ Demolition*,- describe structure:
❑ Moving* - (provide copy of DPW moving license)
* Type of structure: from where (plat/lot or address):
to where (plat/lot or address): number of dwelling units:
number of bedrooms per dwelling unit:
COMMERCIAL LUUL
❑ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged) EfGRESS
dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered as an alteration, cotherwise will
be included in new construction. (see Code Section 3603.21 for residential and Article 10 for commercial),
❑ Temporary struc
ture - includes when allowed, trailers, tents and the like and only for limited periods of time. Describe
SECTION - 8 MECHANICAL & PRIMARY FUEL
❑ 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):
HVAC` (combined unit) ,- primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
❑ Required: plans provided plans not provided; why?
❑ Not required; not to be installed, why?
SECTION - 10 RE UIRED OFF-STREET PARKING for Zoning and Architectural Access
❑ Parking plan submitted to: Building Dept. Planning Board date submitted
provided
Number of spaces - indoors outside total p
Handicap spaces required yes no if yes, how many as a part of the total required number
Is Route 6 (State Road) entrance permit required? yes no if yes, has it been issued? yes Mo
Submit copy of application and/or permit as soon as available.
SECTION- 11 IDENTIFICATION
11.1 Architect/Engineer - for overall design
Company Name:
Address:
Phone#:
Certified by State of Massachusetts as:
Certification_ Number:
Note: Signatures and seals on all plans affidavits, &� other documents SHALL BE originals and not reproductiions.
11.2 Architect/Engineer - project supervision and reports
Company Name:
Address:
Phone'#:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on allplans affidavits & other documents SHALL BE originals and not reproducttions.
11.3 General Contractor
Company Name:
Address:"
Phone #:
Construction Supervisors License Number -
Note: Signatures and seals on all plans affidavits, & other documents SHALL BE originals and not reproductions.
i
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COMMERCIAL 2002 COT T.IERCIAL 2002
$25.00 APPLICATION FEE IS NON-REFUNDABLE aC NON-TRArgSFERAI3L.'.E
SECTION -'12 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to nearest dollar. To be completed by permit applicant
1. Building
2. Electrical
3. Plumbing '
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
Estimated Total Cost Including Labor: $ �� , 00
SECTION 13A - OWNER AUTHORIZATION to be completed when owner's agent or contractor al2l2lies for building ermit
pleaseprint)
k4A,4s Owner of the subject property hereby authorize ! ti� 0
to act on my behalf, in all matters lative to w rk authorized by this building permit application.
Signatur of Owner Date
1 SECTION 13B - OWNER/AUTHORIZED AGENT DECLARATION
I, w 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.
Sighed under the painS and penalties erjury.
Z
Signature Owner/A nt Date
-- SECTION 14 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: 5. DENIED (see project review worksheet):
2. 30 clays to review period expires: Date:
3. OK to issue date: 6. HOLD reason:
4. OK to issue subject to requested submittals (see project bate:
review worksheet): Date: 7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature: Date: 9 — 2 3 - 9 Z
SECTION 15 - APPLICANT NOTIFICATION
Applic i fo' ed of above Date: ��O.c7Z Time: Clerk:
Co zeints: ^
n
SECTION 16 - FEE/PERMIT NOTES
otal Permit Fee: 15 7 6
Less Application Fee: $ 25.00
Remaining Balance`. SZ)'
rosy Area -New Construction
oss Area -Alteration
Pe it Issued To:
" T" DARTMOUTH BUILDING DE ARTVIENT
g " 400 Slocum Road, P.O. Box 79399
DATE RECEIVFFD
Y ' Dartmouth; MA 02747
508-910-1820 FAX 508-910-1838
Pi
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING (includes 3 or more ffamily dwellings)
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBETO
DATE SENT FOR REVIEW:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE: ( - 28 -•D Z
Building mmissioner/Inspector of Buildings
Zoning District: Proposed Use: Zone: ❑ C ❑ B ❑ A ❑ V Aquifer Zone
THE F LOWING GENCIES SHOULD BE NOTIFIED:
oard of Board of El Con. ❑Demo ❑ DPW ❑ Elec. ❑Energy ReY»ort
Appeals Health Com. Affidavit Card Sent Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning ❑ Sewer Card ❑ Water Card ❑ Water Division ❑ Zoning ❑ Other
Chief Cut Off Board* / Cut Off / Cut Off Cross Connection Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT
DEPARTMENTAL APPROVAL
q
Zoning Review: Signature:l Date: ----- �—
Energy Report: Signature: Date:
Fire Chief. Signature: 4PL Date: rr ��
Board of Health: Signature:
Conservation Commission: Si -,,.nature: j 'Date:
Other: al 0,nature: l � ' . Date: f
a
Description of Work eing orn:ed:
SECTION 1 - SITE INFORMATION
1.1 NUMBER OF PLANS SUBMITTEDD:
1.2 SITE PLAN SUBMITTED: ❑ yes ❑ nfo
1.3 Property Address: -1
1.4 Assessors Plat & Lot Number:
Nearest Cross Street: V:,�v yJV-k 6nKfLc-
Bus. Name: Phone 74,0
Plat Lot -
Total Land Area Sq. Ft.: <t< V
1.5 Water Supply (MGL c 40 § 54):
1.6 Sewage Disposal System:
❑ Municipal ❑ Private Well
❑ Municipal ❑ On Site Disposal System
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
Contact Address Telephone
Name (print) i `
2.2 Autlorized Agent:
Name (print)
Contact Address Telephone
A `71
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