Treasurer’s: __________
BOH:_____
DPW:______ Conservation Comm : _________
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: ____________
Date Applied: ______________
Building Official: _______________________
SECTION 1: LOCATION (Please indicate Block # and Lot # for locations for which a street address is not available)
___________________________ Stoneham MA 02180 _______________________________ _______________
No. and Street City /Town Zip Code Name of Building (if applicable) Parcel ID
SECTION 2: PROPOSED WORK
Edition of MA State Code used _____ If New Construction check here or check all that apply in the two rows below
Existing Building
Repair
Alteration
Demolition (Please fill out and submit Appendix 1)
Change of Use
Change of Occupancy
Other Specify:___________________________________________
Are building plans and/or construction documents being supplied as part of this permit application? Yes No
Is an Independent Structural Engineering Peer Review required? Yes
No
Brief Description of Proposed Work:__________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
SECTION 3: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION, OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34)
Existing Use Group(s): __________________________________________
Proposed Use Group(s):__________________________
SECTION 4: BUILDING HEIGHT AND AREA
Existing
Proposed
No. of Floors/Stories (include basement levels) & Area Per Floor (sq. ft.)
Total Area (sq. ft.) and Total Height (ft.)
SECTION 5: USE GROUP (Check as applicable)
A: Assembly A-1 A-2 Nightclub A-3 A-4 A-5
B: Business
E: Educational
F: Factory F-1 F2
H: High Hazard H-1 H-2 H-3 H-4 H-5
I: Institutional I-1 I-2 I-3 I-4
M: Mercantile
R: Residential R-1 R-2 R-3 R-4
S: Storage S-1 S-2
U: Utility
Special Use and please describe below:
Special Use:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA IB
IIA IIB
IIIA IIIB
IV
VA VB
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply:
Public
Private
Flood Zone Information:
Check if outside Flood Zone
or indentify Zone:__________
Sewage Disposal:
Indicate municipal
or on site system
Trench Permit:
A trench will not be
required or trench
permit is enclosed
Debris Removal:
Licensed Disposal Site
or specify:_____________
______________________
Railroad right-of-way:
Not Applicable
or Consent to Build enclosed
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: _________ Use Group(s): __________ Type of Construction: ________ Occupant Load per Floor: ______________
Does the building contain an Sprinkler System?: _________ Special Stipulations: ___________________________________________
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
__________________________ ______________________________ ____________________________________________ ___________
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information:
_______________________________ _____-_____-___________ ____-_____-___________ _______________________________
Signature Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
______________________________ __________________________________ ___________________ ______ _____________
Name & Signature Street Address City/Town State Zip
to act on the property owner’s behalf, in all matters relative to work authorized by this building permit application.
SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu. ft. of enclosed space and/or not under Construction Control then check here and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
______________________________ ____-_____-___________ _________________________
Name & signature (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
_______________ _______________
Discipline Expiration Date
10.2 General Contractor
__________________________________________________________________________________________________________________
Company Name
_________________________________________ _________________________________ __________________________________
Name of Person Responsible for Construction Signature License No. and Type if Applicable
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
____-____-_______________ _____-_____-_____________ ____________________________________________________
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
A Workers’ Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes No
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item
Estimated Costs: (Labor
and Materials)
Total Construction Cost (from Item 6) = $_________________
Building Permit Fee = Total Construction Cost x ____ (Insert here
appropriate municipal factor) = $________.
Note: Minimum fee = $________ (contact municipality)
Enclose check payable to __________________________________
(contact municipality) and write check number here ______________
1. Building
$
2. Electrical
$
3. Plumbing
$
4. Mechanical (HVAC)
$
5. Mechanical (Other)
$
6. Total Cost
$
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
______________________________________________________ ____________________________ ____ -_____- ________ _________
Please print and sign name Title Telephone No. Date
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: ____________________________________ _____________
Name Date
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signature
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signature
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Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark “x” where applicable
No.
Item
Submitted
Incomplete
Not Required
1
Architectural
2
Foundation
3
Structural
4
Fire Suppression
5
Fire Alarm (may require repeaters)
6
HVAC
7
Electrical
8
Plumbing (include local connections)
9
Gas (Natural, Propane, Medical or other)
10
Surveyed Site Plan (Utilities, Wetland, etc.)
11
Specifications
12
Structural Peer Review
13
Structural Tests & Inspections Program
14
Fire Protection Narrative Report
15
Existing Building Survey/Investigation
16
Energy Conservation Report
17
Architectural Access Review (521 CMR)
18
Workers Compensation Insurance
19
Hazardous Material Mitigation Documentation
20
Other (Specify)
21
Other (Specify)
22
Other (Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
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