BP-39925COMMERCIAL
COMMERCIAL
3.1 Licensed Construction Supervisor:
Name of Construction Supervisor
Address
Signature
Telephone
Not Applicable ❑
License Number
Expiration Date
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
Thefollowing 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 / Industrial (see Code Section 305.0)
❑)High Hazard - (see Code Section 306.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
❑ Mercantile - retail stores (see Code Section 308.0)
El 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:
Describe the proposal briefly, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing
condition(if extra space is needed, attach an additional sheet):9-& y`� ,,,y. ✓ s [ � 4
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❑ 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:
0 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, 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) - - - - -
* 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:
❑ Replacement doors and windows - (for existing only) (only where doors and windows exist and will nott be enlarged) EGRESS
dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered, as an alteration, otherwise will
be included in new construction. (see Code Section 3603.21 for residential and Article 10 for commercyial).
❑ Temporary structure - includes, when allowed, trailers, tents and the like and only for limited periods off time. Describe:
✓�i� vu '�� 4150
❑ 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
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❑ Required: plans provided plans not provided, why?
❑ Not required, not to be installed, why?
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❑ Parking plan submitted to: Building Dept. Planning Board date,rsubmitted
Number of spaces indoors outside totall 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 issiued? yes no
Submit copy of application and/or permit as soon as available.
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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 aind not reproductions.
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 all plans, affidavits, & other documents SHALL BE originals aired not reproductions.
11.3 General Contractor
Company Name:
Address:-
Phone #: 5`�S
Construction Supervisors License Number
Note: Signatures and seals on all plans, affidavits, & other documents SHALL BE originals arnd not reproductions.
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COMMERCIAL
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
IAL
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I2 E - SiR QiCOST
Item Estimated Cost ($) to nearest dollar. To be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (I + 2 + 3 + 4) Estimated Total Cost Including Labor: $ ��
(p se prinf
as Owner of the subject property hereby authorize
,���true
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application and accurate, to the best of my knowledge and belief.
Si and r the pains and penal of perjury.
r
Sign e o weer/Agent Date
1. HOLD reason: 3. OWNER/CONTRACTOR NOTIFIED ON
Date: Date:
2. HOLD subject to Zoning Board of Appeals
action:
i
4. Comments:
5. Inspector's Signature:
Applicant irTformed of above Date: Time: Clerk:
Comments:;
Total Permit Fee: I Less Application Fee: $ 25.00 I Remaining Balance:
Gross Area - New Construction
;Gross Area. - Alteration
Permit Issued To:
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