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Building-permit-application-1-2-family-only 780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS

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ALL ITEMS UNDERLINED IN RED MUST BE COMPLETED!
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
FOR
MUNICIPALITY
USE
Revised March 3,
2016
Building Permit Application Number:__________________ This Section For Official Use Only
Building Permit Number: _____________________
Date Applied: ______________________________
Signature: __________________________________________ ________________________Plans E-filed:_______
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
____________________________________________
1.1a Is this an accepted street? yes_____ no_____
1.2 Assessors Map & Parcel Numbers
_____________________ ____________________
Map Number Parcel Number
1.3 Zoning Information:
_______________ ___________________
Zoning District Proposed Use
1.4 Property Dimensions:
_____________________ ____________________
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.7 Flood Zone Information:
Zone: ___ Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP
1
2.1 Owner
1
of Record:
________________________________________ ________________________________________________
Name (Print) Address for Service:
____________________________________________ ____________________________________________________
Signature Telephone
Email Address_________________________________________
SECTION 3: DESCRIPTION OF PROPOSED WORK
2
(check all that apply)
New Construction
Existing Building
Owner-Occupied
Repairs(s)
Alteration(s)
Addition
Demolition
Accessory Bldg.
Number of Units_____
Other Specify:________________________
Brief Description of Proposed Work
2
:_________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
(Labor and Materials)
Official Use Only
1. Building
$
1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost
3
(Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:_________________________________________________
____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:__________
2. Electrical
$ XXXXXX
3. Plumbing
$ XXXXXX
4. Mechanical (HVAC)
$
5. Mechanical (Fire
Suppression)
$
6. Total Project Cost:
$
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
_______________________________________________
Name of CSL- Holder
_______________________________________________
Address
________________________________________
Signature
_____________________
Telephone
_____________________ ______________
License Number Expiration Date
List CSL Type (see below) _______________
Type
Description
U
Unrestricted (up to 35,000 Cu. Ft.)
R
Restricted 1&2 Family Dwelling
M
Masonry Only
RC
Residential Roofing Covering
WS
Residential Window and Siding
SF
Residential Solid Fuel Burning Appliance Installation
D
Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
______________________________________________________________
HIC Company Name or HIC Registrant Name
______________________________________________________________
Address
________________________________________ ____________________
Signature Telephone
_____________________________
Registration Number
______________________________
Expiration Date
Email Address
SECTION 6: 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 ………. No ………..
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER’S 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
SECTION 7b: OWNER
1
OR AUTHORIZED AGENT DECLARATION
I, ______________________________________________________, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
____________________________________________________________________________________________
Print Name
_____________________________________________________________ _____________________________
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) _________________________ (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) __________________ Habitable room count ______________________
Number of fireplaces______________________ Number of bedrooms _____________________
Number of bathrooms ____________________ Number of half/baths ______________________
Type of heating system ___________________ Number of decks/ porches __________________
Type of cooling system_____________________ Enclosed ______________Open _____________
3. “Total Project Square Footage” may be substituted for “Total Project Cost”

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‐contractors listedontheattached
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.policynumber.
Iamanemployerthatisprovidingworkers’compensationinsuranceformyemployees.Belowisthepolicyandjobsiteinformation.
InsuranceCompanyName:__________________________________________________________________________________________________
Policy#orSelf‐ins.Lic.#:_______________________________________________ExpirationDate:______________________________________
JobSiteAddress:__________________________________________________________________________________________________________
Attachacopyoftheworkers’compensationpolicydeclarationpage(showing
thepolicynumberandexpirationdate).
FailuretosecurecoverageasrequiredunderMGL.c.152,§25Aisacriminalviolationpunishablebyafineupto$1,500.00and/orone‐year
imprisonment,aswellascivilpenalties intheformofaSTOPWORKORDERandafineofup
to$250.00adayagainsttheviolator.Acopyofthis
statementmaybeforwardedtotheOfficeofInvestigationsoftheDIAforinsurancecoverageverification.
Idoherebycertifyunderthepainsandpenaltiesofperjurythattheinformationprovidedaboveistrueandcorrect,andthatclicking
this
checkboxandtypingmynameinthefieldbelowwillactasmysignature.
Name:__________________________________________________Date:___________________________________________________________
Phone#:________________________________________________Email:__________________________________________________________

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.
T
NT
e Street
BOX 56
0
93-2651
TOWN OF BELMON
OFFICE OF COMMUNITY DEVELOPME
19 Moor
P. O.
BELMONT, MASSACHUSETTS 02478-090
Telephone: (617) 993-2664 Fax: (617) 9
HOMEOWNER LICENSE EXEMPTION
DATE ___________________
JOB LOCATION ______________________________________________________________________
Number Street Address Section of Town
“HOMEOWNER” _____________________________________________________________________
Name Home Phone Work Phone
PRESENT MAILING ADDRESS _________________________________________________________
_____________________________________________________________________________________
City/Town State Zip Code
DEFINITION OF A HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be,
a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person
who constructs more than one home in a two-year period shall not be considered a homeowner.
The undersigned “homeowner” certifies that he/she understands the Town of Belmont Building Department minimum
inspection procedures and requirements and that he/she will comply with said procedures and requirements.
"Persons contracting with unregistered contractors do not have access to the guaranty fund (as let forth in MGL
c.142A)"
HOMEOWNER’S SIGNATURE
________________________________________________________
APPROVAL OF BUILDING OFFICIAL _________________________________________________
Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section
116.0, Construction Control.
“Persons contracting with unregistered contractors do not have access to the guaranty fund (as set forth in
MGL c.142A).”
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 one (1) copy, two (2) if adding a
bedroom 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.
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.
17. Demolition Delay Bylaw: is applicable to all structures identified as Significant Buildings by the
Belmont Historic District Commission.
18. Stormwater Management and Erosion Control Bylaw: is applicable to all commercial projects and new
residential construction, except Alterations unless associated with the Substantial Demolition of One,
Two and Three family residential properties.
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 divsion 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 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
617-993-2661
FIRE PREVENTION
617-993-2210
PLUMBING & GAS
617-993-2662
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)
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-1-2-family-only 780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS

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Completed 11 July 2020

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