BP-57022COMMERUAL
Not Applicable
le
Ti—p�
.l Licensed Construction Supervisor:
4
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Name of Construction Supervisor
w V t� License Number
,n
Address Expiration Date
Telephone
Workers Compensation Insurance affidavit 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 (MGL 152 Section 25A)Signed Affidavit Attached: ❑ yes ❑..no....•.., ..•.......•
❑ new construction ❑addition ❑
❑ repairs ❑ accessory bldg. (shed/garage)
other (specify Sec. 6): - ❑ demolition ❑ sign ❑ replacement window/door no of windows doors
X.
>.":llt�;17:1?1i>3I11r:u�n:�•_ Edition, Code Article 3, as noted See the Code
&e following descriptions are based on the Massachusetts State Building 6th Ed ,
❑ 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 / Industrial (see Code Section 305.0)
❑ High Hazard - (see Code Section 306.0)
❑ In.,ztitutional - hospital, nursing home, infant day care (see Code Section 307.0)
❑ Mercantile - retail stores (see Code Section 308.0)
❑ Residential - three or more family, hotel (see Code Section 309.0)
❑ Storage - includes garage (see Code Section 309.0)
❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
❑ New Tenant -for any of the above, please indicate (see Code Section 119,0 and Zoning By -Law Section 35)
❑ Tent or Trailer - temporary
purpose?
❑Other: d-"
Describe the proposal briefly, INCLUDE number of dwelling units bedrooms or occupant load as app ica le,�alsq existing
condition (if extra space is needed, attach an additional sheet): --►-
%� N
❑ 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.) 0 yes ❑ no
If yes„ see 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 110.1 Code & Appendix I)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR
❑ Demolition* - describe structure:
❑ Moving* - (provide copy of DPW moving license)
* from where (plat/lot or address):
Type of structure:
number of dwelling units:
to where (plat/lot or address):
number of bedrooms per dwelling unit:
rev March 17 7004
r.•\hlrla fnnns\hlriannn rnm . Paaa 2
as Owner/Authorized Agent hereby declare that the statements and information
on she foreg,6ing application are true and accurate, to the best of my knowledge and belief.
Sign under the pains Od penalties of perjury. v'
Signature of
Date
1. Date plan reviewed: 5.. DENIED (see project review worksheet):
2. 30 days to review period expires: Dater
3. OK to issue date: 6. HOLD reason:
4. 'OK to issue subject to requested submittals (see project Date:
review worksheet): Date: 7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector'sSignatur . Date: ;jj1N I .,srnn
Total Permit Fee: / 6T,,S .—
Gross Area - New Constructio
Gross Area - AlteratJ'—'-
Permit Issued To:
Less Application Fee: $ 25.00 Remaining Balance: l (`
Zoning Review:
Signature-"
Date:
Energy Report:
Signature: -
Date;:
Fire Chief:
Signature:
Date!:
Board of Health:
Signature:
Date;:
Conservation Commission:
Signature:
Date,:
Other:
Signature:
Dater
Description of Work Being Performed. 1,/0 ( r,
/
Yk M. I C1 J
1.1 ER OF PLANS SUBMITTED:
.3 Property Address:
Nearest Cross Street: e- e,
Bus: Name: ()Ja 45L I e, 1 Phone#1''t�5'f
Totalland Area Sq. Ft.:
1.5 Water Supply (MGL c 40 § 54):
❑ Municipal ❑ Private Well
1.2 SITE PLAN SUBMITTED: ❑ yes ❑ no 4
1.4 Assessors Plat & Lot Number:
Plat Lot, -
-wage liisPosai .3ysLciu.
❑ Municipal ❑ (On Site Disposal System
2.1 Owner of Record: /� -7-7 61'
Tame (print) Contact'Address Telephone
2.2 Authorized Agent:
(Ai U0_ Ck vk
Name (print) Contact Address Telephone
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qrr.b17 7004