Fillable Building Permit Application - Commercial (Town of Belmont)

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Building Permit Application - Commercial (Town of Belmont)

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ALL ITEMS UNDERLINED IN RED MUST BE COMPLETED!
The Commonwealth of Massachusetts
State Board of Building Regulations and
Standards
Massachusetts State Building Code
780 CMR
Town of Belmont
Office of Community Development
19 Moore Street
Belmont, MA 02478
Revised 2/27/04
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY
BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING
This Section For Official Use Only
Building Permit Number:
Date Received:
Signature:
Building Commissioner/Inspector of Buildings Date Issued
SECTION 1 – SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map & Parcel Number
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Property Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
/
/
1.6 Water Supply (M.G.L. c.40.§ 54)
Public Υ
1.7 Flood Zone Information:
Zone: Outside Flood Zone Υ
Municipal Υ On site disposal system Υ
SECTION 2 – PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Address
Signature Telephone
2.2 Authorized Agent:
Name (Print) Address
Signature Telephone
SECTION 3 – CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
Signature Telephone
Not Applicable ٱ
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Company Name
Address
Signature Telephone
Not Applicable ٱ
Registration Number
Expiration Date
Page 2
SECTION 4 – WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152 § 25C (6) )
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.
Signed Affidavit Attached Yes …..ٱ No……ٱ
SECTION 5 – PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES – FOR BUILDINGS AND STRUCTURES SUBJECT
TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 107.6 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED
SPACE)
5.1 Registered Architect:
Name ( Registrant)
Address
Signature Telephone
Not Applicable ٱ
Registration Number
Expiration Date
5.2 Registered Professional Engineer(s):
Name ( Registrant)
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name ( Registrant)
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name ( Registrant)
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name ( Registrant)
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
5.3 General Contractor
Company Name
Responsible In Charge of Construction
Address
Signature Telephone
Not Applicable ٱ
Page 3
SECTION 6– DESCRIPTION OF PROPOSED WORK (check all applicable)
New Construction ٱ
Existing Building ٱ
Repair (s) ٱ Alteration (s) ٱ
Addition ٱ
Accessory Bldg. ٱ
Demolition ٱ
Other ٱ Specify:
Brief Description of Proposed Work:
SECTION 7– USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A
Assembly
ڤ
A-1
A-4
ڤ
ڤ
A-2
A-5
ڤ
ڤ
A-3
ڤ
1A
1B
ڤ
ڤ
B
Business
ڤ
2A
2B
2C
ڤ
ڤ
ڤ
E
Education
ڤ
F
Factory
ڤ
F-1
ڤ
F-2
ڤ
H
High Hazard
ڤ
3A
3B
ڤ
ڤ
I
Institutional
ڤ
I-1
ڤ
I-2
ڤ
I-3
ڤ
M
Mercantile
ڤ
4
ڤ
R
Residential
ڤ
R-1
ڤ
R-2
ڤ
R-3
ڤ
5A
5B
ڤ
ڤ
S
Storage
ڤ
S-1
ڤ
S-2
ڤ
U
Utility
ڤ
Specify:
M
Mixed use
ڤ
Specify:
S
Special Use
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
SECTION 8– BUILDING HEIGHT AND AREA
BUILDING AREA
Existing (if applicable)
Proposed
Number of Floors or stories include
Basement levels
Floor Area per Floor (sf)
Total Area (sf)
Total Height (ft)
SECTION 9– STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ……ڤ No ……ڤ
SECTION 10a – OWNER AUTHORIZATION – TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
Authorize to act on my behalf, in all matters relative to
work authorized by this building permit application.
Signature of Owner Date
Page 4
SECTION 10b– OWNER/AUTHORIZED AGENT DECLARATION
I, , 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.
“
Persons contracting with unregistered contractors do not have access to the guaranty fund (as let forth in MGL c.142A)"
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner / Agent Date
SECTION 11– ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
completed by permit applicant
Official Use Only
1. Building
Estimated Total - (a) Cost of
construction from #4 rounded up to
nearest $1,000
2. Mechanical (HVAC)
3. Fire Protection
Building Permit Fee (4/1/02)
15 x (a) ÷ 1,000 (Minimum $50)
4. Total = ( 1 + 2 +3 )
Check Number
SECTION 12– OFFICAL USE ONLY
Notes:
Rev. 1/17/2019
TOWN OF BELMONT
OFFICE OF COMMUNITY DEVELOPMENT
19 Moore Street
P. O. BOX 56
BELMONT, MASSACHUSETTS 02478-0900
Telephone: (617) 993-2664 Fax: (617) 993-2651
DEBRIS FORM
Will there be a dumpster on site? □YES
□NO
Debris will be removed daily by trailer □
In accordance with the provisions of MGL c 40, S 54, a condition of issuance of a BUILDING PERMIT is that
the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal as defined by
MGL c 111, S 150A. The debris will be disposed of at:
Name of Facility
________________________________
Signature of Permit Applicant
________________________________
Date
CONTACT THE BELMONT BOARD OF HEALTH FOR FURTHER INSTRUCTIONS & REGULATIONS
617-993-2720
WARNING: This document merely certifies that the above referenced building complies with applicable provisions of the State
Building Code. No opinion is expressed or warranty given is to any potential health hazard not addressed by the State Building Code
including, but not limited to, the presence of radon, lead paint, asbestos, and urea formaldehyde.

TheCommonwealthofMassachusetts
DepartmentofIndustrialAccidents
1CongressStreet,Suite100
Boston,MA02114‐2017
www.mass.gov/dia

Workers’CompensationInsuranceAffidavit:Builders/Contractors/Electricians/Plumbers.
TOBEFILEDWITHTHEPERMITTINGAUTHORITY.

ApplicantInformation
Name
(Business/Organizational/Individual)
:________________________________________________________________________________________
Address:___________________________________________________________________City:_________________________________________
State:______________________________Zip:___________________Phone#:______________________________________________________
Areyouanemployer?Checktheappropriate box: Typeofproject(required):

1. Iamanemployerwithemployees(fulland/orparttime)*

7.Newconstruction
2. Iamasoleproprietororpartnershipandhavenoemployeesworkingformeinany
capacity.[Noworkers’comp.insurancerequired.]
8.Remodeling
9.Demolition
3. Iamahomeownerdoingallworkmyself.[Noworkers’comp.insurancerequired]†
10.Buildingaddition
4. Iamahomeownerandwillbehiringcontractorstoconductallworkonmyproperty.
Iwillensurethatallcontractorseitherhaveworkers’compensationinsuranceorare
soleproprietorswithnoemployees.
11.Electricalrepairsoradditions
12.Plumbingrepairsoradditions

5. IamageneralcontractorandIhavehiredthesub‐contractorslistedonthe attached
sheet.Thesesub‐contractorshaveemployeesandhaveworkers’comp.insurance.±
13.RoofRepairs
6. WeareacorporationanditsofficershaveexercisedtheirrightofexemptionperMGL.
c.152,§1(4),andwehavenoemployees.[Noworkers’comp. insurancerequired.]
14.Other
*Anyapplicantthatchecksbox#1mustalsofilloutthesectionbelowshowingtheirworkers’compensationpolicyinformation.
†Homeownerswh osubmit thisaffidavitindicangtheyaredoingallworkandthenhireoutsidecontractorsmustsubmitanewaffidavitindicatingsuch.
±Contractorsthatcheckthisboxmustattach
anadditionalsheetshowingthenameofthesub‐contractorsandstatewhetherornotthoseentitieshave
employees.Ifthesub‐contractorshaveemployees,theymustprovidetheirworkers’comp.policynumbe r.
Iamanemployerthatisprovidingworkers’compensationinsuranceformyemployees.Belowisthepolicyandjobsiteinformation.
InsuranceCompanyName:__________________________________________________________________________________________________
Policy#orSelf‐ins.Lic.#:_______________________________________________ExpirationDate:______________________________________
JobSiteAddress:__________________________________________________________________________________________________________
Attachacopyoftheworkers’compensationpolicydeclarationpage(showing
thepolicynumberandexpirationdate).
FailuretosecurecoverageasrequiredunderMGL.c.152,§25Aisacriminalviolation punishablebyafineupto$1,500.00and/orone‐year
imprisonment,aswellascivilpenalties intheformofaSTOPWORKORDERandafineofup
to$250.00adayagainsttheviolator.Acopyofthis
statementmaybeforwardedtotheOfficeofInvestigationsoftheDIAforinsurancecoverageverification.
Idoherebycertifyunderthepainsandpenaltiesofperjurythattheinformationprovidedaboveistrueandcorrect,andthatclicking
this
checkboxandtypingmynameinthefieldbelowwillactasmysignature.
Name:__________________________________________________Date:___________________________________________________________
Phone#:________________________________________________Email:__________________________________________________________

Page 7
TOWN OF BELMONT
OFFICE OF COMMUNITY DEVELOPMENT
19 Moore Street
P. O. BOX 56
BELMONT, MASSACHUSETTS 02478-0900
Telephone: (617) 993-2664 Fax: (617) 993-2651
BUILDING PERMIT/CONSTRUCTION PROCESS
The Massachusetts State Building Code (780 CMR) allows Building Departments thirty (30) days to act
on a building permit application. Building permits are usually issued within ten days assuming all
required information detailed below is provided at the time of original submission.
1. The Building Permit application
- completed and signed by the homeowner or his/her authorized
agent.
2. The fee
is based on $15.00 per $1,000 of construction cost with a minimum fee of $50.00.
3. The Homeowner License Exemption Form
-is required for work involving a single or two family
residence if:
1)the contractor does not have a State Construction Supervisors License, or
2)the homeowner is seeking the building permit.
4. The Debris Form
must be completed indicating where debris from the construction site will be
disposed. Note: The Town’s residential trash collection does not included construction debris.
5. The Workers’ Compensation Insurance Affidavit-
must be completed by the license contractor or the
homeowner performing the work.
6. Valid licenses
and a photo I.D. must be presented at the time of application.
7. A plot plan
stamped by a Massachusetts Registered Land Surveyor must be submitted with every
building permit application for the construction of a new building, an accessory building, or an
addition to an existing building. All plans must conform to the “Regulations for Plot Plans for
Building Permits” and must include existing and proposed open space and lot coverage percentages.
8. Plans and Specifications
: Every application must be accompanied by two (2) copies of specifications
and plans drawn to scale with sufficient clarity, detail and dimensions to show the nature and
character of the work to be performed.
All plan sets larger than 11x17 must also
include a .pdf version or CD of the plans
. This information will be thoroughly reviewed
to determine code compliance. The degree of completeness and accuracy will have a direct bearing
on the time required for review and approval. Plans should include but not be limited to:
Foundation plan with anchor bolt locations and clearly showing a minimum four (4) foot depth to
bottom of all footings.
Structural, mechanical and electrical plans in sufficient detail to determine code compliance.
(Include exterior building envelope component materials with R-values, heat loss information,
HVAC sizing, etc. for energy code compliance in accordance with Appendix J of 780 CMR
Massachusetts State Building Code.)
All plans and specifications for any building containing more than 35,000 cubic feet of enclosed
space, except single or two-family dwelling(s), must be stamped and signed by a qualified
registered professional engineer or architect.
9. A dumpster permit
must be obtained from the Health Department if a dumpster will be utilized in
conjunction with this project.
Page 8
10. The Conservation Commission must approve any construction that is proposed within an area subject
to control by the Wetlands Protection Act and/or the Rivers Protection Act. Wetlands maps are
located within this office.
11. The Board of Health
must approve any construction that is proposed for any food service
establishment.
12. The Belmont Fire Prevention Office
must review and approve all plans for fire protection, as
required by building code, for additions and/or major renovations.
13. The Historic District Commission
must approve any exterior work in the Historic District. Historic
District “Rules & Regulations”, “Application & Instructions”, and maps are located in this office.
14. The Planning Board
must approve any new or expanded driveway opening in the stone walls or tree
work adjacent to Somerset Street, since this street is designated a “Scenic Road”.
15. A special permit and/or variance
will be required from the Zoning Board of Appeals if the proposed
construction does not conform to current zoning regulations.
16. The building permit must be posted
at the site in clear view and protected from the weather at all
times until the final inspection or Certificate of Use and Occupancy is issued.
The following is a list of the minimum required inspections to be performed. It is the applicant’s
responsibility to notify each inspector at least 24 hours in advance of each required inspection. Building
inspections are done Monday-Friday, 10:00 a.m. to 12:00 noon. Note: These are the minimum
inspections required; complex projects may require additional inspections. It is the applicant’s
responsibility to contact the building commissioner to discuss any additional inspections, which may be
required.
1. Excavation: Inspection must occur prior to the installation of footings or
forms.
2. Foundation: Inspection must occur after foundation walls are erected,
damp proofed, and perimeter drain installed but prior to any backfilling.
3. Framing: Inspection must occur after all framing is completed, but prior to the installation
of any insulation or finish material. All plumbing, gas, fire detection systems, and
electrical “rough” work must be completed and approved by appropriate inspector
prior to this inspection.
4. Insulation: Inspection must occur after all insulation, baffles, and vapor
barriers are installed but prior to the installation of any finish material or wallboard.
5. Final: The inspection must occur upon completion of all work and approval by plumbing, gas,
electrical and/or fire alarm inspectors but prior to occupancy of any new building or
part thereof.
If you have any additional questions regarding the building permit process, please call the Office of
Community Development Building Division at (617) 993-2664 between the hours of 8:00-10:00 a.m.
Monday-Friday.
LIST OF PHONE NUMBERS
BUILDING INSPECTOR
617-993-2664
SCHEDULE INSPECTIONS
617-993-2663
ELECTRICAL INSPECTOR
617-484-2780
FIRE PREVENTION
617-489-4848
PLUMBING & GAS
617-993-2662
ELECTRICAL
617-993-2661
Page 9
Sustainable Building Design Policy
Unanimously approved by the Belmont Board of Selectmen
March 5, 2007
From “A Working Vision for Belmont’s Future:”
“We, the Belmont community, make a commitment to . . . develop and use our human and
financial resources wisely. . . . We will be an environmentally responsible community and
conserve our natural habitats.”
Purpose
In support of Belmont’s Working Vision, we seek to make the best possible use of all of our
resources (both natural and manmade) in a way that realizes the full potential of cost savings and
environmental benefits while still being fiscally responsible. Toward these goals, the Town of
Belmont supports a sustainable design policy that promotes practices that protect human health
and well being, and the natural environment.
The Town of Belmont, both as a matter of principle and as a cost-saving measure, supports
efforts that will achieve the following benefits of sustainable design as applied to new
construction and major renovation of all municipal and school district buildings, to the extent
practical:
Economic benefits that reduce operating costs; enhance asset value; improve employee
productivity and satisfaction; and optimize life-cycle economic performance
Environmental benefits that enhance and protect ecosystems and biodiversity; improve air
and water quality; reduce solid waste; and conserve natural resources
Health and community benefits that improve air, thermal, and acoustic environments;
enhance occupant comfort and health; minimize strain on local infrastructure; and
contribute to overall quality of life
These benefits can be achieved by many design and construction initiatives, including but not
limited to:
Site planning and design:
Involving contractors, engineers, and other relevant parties in early planning discussions to
ensure building systems (e.g., HVAC, electrical) are sited and sized properly in building
design
Planning building design to minimize impact on natural ecosystems (e.g., wildlife habitats,
wetlands, forests) or municipal resources (e.g., water supply, sanitary sewer system, storm
water drainage, electric load)
Designing landscaping to use native species and conserve water
Designing to encourage pedestrian and bicycle access, and access and amenities to
encourage use of public transit where possible
Resource-efficient elements:
Using construction materials that are fully or partially comprised of recycled content,
and/or are recyclable at the end of their useful lifetime
Using nontoxic materials for building envelope and interior (e.g., fiberboard, paint,
adhesives, carpeting, and other materials that contain low levels of volatile organic
compounds (VOCs)
Implementing natural lighting and ventilation systems (e.g., daylighting, fresh air
circulation)
Page 10
Using equipment and appliances that maximize operating efficiency (e.g., occupancy
sensors, low-flow water fixtures, Energy Star-rated HVAC systems)
Incorporating alternative energy into building systems (e.g., solar hot water, solar panels,
geothermal heat pumps, wind turbines, biodiesel backup generators)
Construction:
Using diesel construction equipment that has been retrofitted with pollution controls to
minimize exposure to harmful exhaust contaminants
Recycling waste materials from building construction (or demolition)
Post-construction:
Commissioning engineering systems to ensure specifications have been met
Proper operation of the buildings once occupied (i.e., training employees on using and
maintaining fixtures and equipment) to ensure maximum resource-saving potential
Application
1. The Town of Belmont should incorporate sustainable building principles such as Leadership in Energy
and Environmental Design (LEED), as promulgated by the U.S. Green Building Council, or other
acceptable standards into the design and construction and operation of all municipal and school district
buildings, to the level that is economically practical.
2. Designers selected for all capital projects should be qualified to design buildings and
implement elements that are sustainable and efficient. The design team should include
LEED-accredited or comparable professionals.
3. The project team should meet early in the design stage to realize optimal cost savings and
best practices in energy efficiency, environmental protection, storm water management, and
reduced construction waste. The team should meet regularly throughout the various design
phases and periodically during construction to ensure these practices are being employed.
4. To the extent practical, building and site design should incorporate best-practices in storm
water management; and should incorporate Low Impact Development site design
components.
5. To the extent practical, performance objectives should be incorporated into design,
construction, and contract documents, and a continual performance verification process
should be used throughout the project and at completion.
6. To the extent practical, as determined by the town building committee, all building projects
(whether renovation or new construction) undertaken by the town should conform to
sustainable design principles.
7. School projects (i.e., K–12 public schools) will comply with Massachusetts regulations
(currently CHPS (Collaborative for High-Performance Schools)).
8. The Town’s Permanent Building Committee and project-specific building committees should
fully consider the lifecycle costs of the building when determining the project’s budget,
giving consideration to operating costs, including future utility costs and environmental
costs.
9. The town’s building committees will include in contract documents a statement that all
construction vehicles must observe state anti-idling regulations.
The Belmont Board of Selectmen embraces these policies and practices as they set a leadership example to town
residents, developers, and other communities. The Board also encourages development in the private sector (e.g.,
residential homes and commercial/industrial buildings) to follow the strategies outlined above to ensure maximum
environmental and economic benefit.
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Building Permit Application - Commercial (Town of Belmont)

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Completed 15 July 2020

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