BP-62047i
c SECTION 3.e, ONST RUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: License Number:
Address: Expiration Date:
Signature: Telephone:
ORKERS COMPENSATION INSURANCE,AFFIDAVIT,(MGL.c 152
W §,25) ;
SECTION.4
application. Failure to provide this
Worker's Compensation Insurance Affidavit must be completed and submitted with this pp
Wor p
affidavit will result in the denial of the issuance of the building permit (MGL 152 Section 25A).
Signed Affidavit Aftached: ❑ Yes ❑ No
SECTION 5 = DESCRIPTION OF"PROPOSED WORK {Check all applicable)
Shed/Cara
❑ Accessory Building (e/Other_ g )
� Construction ❑Addition ❑Repairs ►•Y
I
❑ New
f ❑ Re lacement window/door
` Sec. 6 ❑ Demolition �n P
❑ Other (Specify S )
No. of Windows Doors
❑ Fire Protection
ED PROJECT,USE INCLUDING THREE FAMILY OR MORE:AND EXEMPT USES
SECTION. 6'=`PROPOS
1 The followfrrg descriptions are based on the Massachusetts State Building 7th Edition, Code Article 3, as noted. See the Code,
❑ Assembly -:restaurant, lounge, theater, school, etc.
(see Code
Section
303
0
)
Describe:
i Code Section 304.00
assembly with less then 50 occupants -indicate Medical or other professional {see )
❑ Business -office, asse y ;
❑ Educa
tion - struction for training including child day care for those over 2 year 9 months (see Code Section 305.0)
Factory/Industrial (see Code Section 306.0)
❑ High Hazzard (see Code Section307.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 308.0)
❑ Mercantil
e - retail stores see Code Section 309.0) -
❑ Residential -three or more family, hotel (see Code Section 310.0)
❑ Storage - including garage (see Code 311.0)
❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
Code Section 110.0
- please indicate see C )
for of the above, ea
❑ New Tenant fo y P
❑ Tent or Trailer - temporary
Purpose?
❑ Other: d
Describe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
it condition (rf extr
a space is needed, attach an additional sheet):
O WORKTO.BE PERFORMED .
SECTION 7:�=TYPE: OPCONSTf2UCTION R '
❑ Demolition*
- describe structure:
❑ Trench Permit Required? ' ❑Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq. ,
❑ Moving* - (provide copy of DPW moving license)
*Type of structure: from where (map/lot or address):
to where (map/lot or address): number of dwelling units:
number of bedrooms per dwelling unit;
❑ Replaceme
nt doors and windows (for existing only) (only where doors and windows exist and will not be enlarged)
EGRESS dimensions must be maintained.
❑ Temporary structure and uses
- includes when allowed, new tenants, trailers, tents and the like and only for limited perirods of time.
,
Describe:
77-7777-7777
SECTION 8 MECHAKICAL;& PRIMARY.zFUEL
❑ 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) Roof Top Unit (RTU) New, ❑ Replacement ❑
t g ( P
None of the above to be provided Mechanical Ventilation. ❑
❑ Hot Water: Gas Electric Fuel Oil Other
7' „•
T pN9:''=SPRINKLERS Ah(U%OR F1RE PR07ECTIQN" 3:CQPCES:OF:PL:ANS AND NARRATI� � RE4UI,REQ
SEC.
❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why? Narrative'Submitted? l❑ Yes ❑ No
Iitectiral Access .
T, ARKING" for-Zoning'and Arc , f
,. .-
SECTION ,10 - REW IRED;OFF. STREE . P
❑ Parking plan submitted to: Building Dept. Planning Board Date submitted
Number of spaces indoors outside Total provided
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 No
Submit copy of application and/or permit as soon as available.
N -1 1DENTtFICAT777-7—
IOR
.. SECTIO 1
. t Z ,
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 reproductions.
11.2 Architect/Engineer - project supervision and reports
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
cubic feet pro posed) - indicate ' Certification Number:
❑ New construction and/or Additional (total gross p p ) 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:
❑ Alteration of existing, no me in gross
increase square feet. A separate Refuse Disposal Declaration is required. 11.3 General Contractor
q
Company Name; -
Will this o•ect be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ Yes ❑ No Address:
P 1
If Yes, see Code Section 116.0 Designer to submit Code Synopsis in additional to original plans and if existing building Section 3402.1.1 Phone #:
No see 110.11.1 Code)Construction Supervisors License Number:
Will this project require Peer Review (over 400,000 cu ft.) ❑Yes ❑ ( Note: Signatures and seals on all plans affidavits & other documents SHALL BE originals and not reproductions.,
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR. Page 3
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