TOWN of BOYLSTON
221 Main St Boylston, MA. 01505
508-869-6064 / fax # 508-869-6210
COMMERCIAL BUILDING PERMIT
BUILDING PERMIT INSTRUCTIONS and APPLICATION
Please be advised that any incomplete and/or not legible applications will be rejected.
IF APPLICABLE THE FOLLOWING INFORMATION Will BE REQUIRED
◊Check Off (Below) Information That Is Submitted With Permit◊
□
Site plans are required for new construction and additions, Plot Plans must be to scale
stamped & signed originals by the engineer.
□ A
certified
As Built foundation plan is required for all work after foundation is set show all
dimensions and off sets.
□
All plans MUST include section drawing for foundation, floor, wall, roof, mechanicals etc.
(THREE SETS REQUIRED). Two set of all ENGINEERED LUMBER all plans must be
stamped by an Engineer or Architect. One set of each will be returned, (
must be on site
for inspections
).
□
Comcheck 3.7.1 IECC 2009 OR ASHRAE 90.1-2010 (or Later) for NEW
CONSTRUCTION and ADDITIONS print two copies have stamped by Engineer or
Architect, one set will be returned, (
must be on site for inspections
)
□ Septic
As Built plans are required for new construction, additions must be approved by
Board of Health
□
Certificate of Insurance for Liability and Workman’s Compensation is required with the
Town of Boylston as Certificate Holder. Workers Compensation Affidavit must be filed.
□
Control Construction Affidavits and Copy of Construction Supervisor License.
□
Copy of the Federal (EPA) storm water permit. If your project disturbs 1 acre or more.
□
If demolition of a structure is involved you need to receive a Demolition Application form
from the building department. Attach copies of NESHAPS building survey ANF-001
asbestos removal and BWP-AQ-06 DEP demolition notication, sign off from all utilities,
Dig Safe number
□
Plans may need third party review and or peer review, plan review fees may apply
□
Make check payable to: Town of Boylston
Applicant MAY need to contact the Town Departments listed on the back for approval
ADDITIONAL INFORMATION MAY BE REQUIRED
Fill out all sections or mark with N/A (not applicable)
Modified 4/1/2010
~
The Commonwealth of Massachusetts
~
Department
of Public Safety
Massachusetts State Building Code (780 CMR) Seventh Edition
Bu
i
lding Permit App
l
ication
for any Building other than a One- or Two-Family
Dwelling
(This Section For Official Use Only)
Building Permit Number:
I
Date Applied:I
Building Inspector:SECTION 1: LOCATION (Please indicate Block #and Lot#for locations for which a street address is not available)
No.and Street City /Town Zip Code Name of Building (if applicable) SECTION 2: PROPOSED WORK
If New Construction check here 0 or checkall that apply inthe two rows below
Existing Building 0 Repair 0
I
Alteration 0I
Addition 0I
Demolition 0 (please fill out and submit Appendix 1)Change of Use 0 Change of Occupancy 0
I
Other 0 Specify:Are building plans and/ orconstruction documents being supplied aspart of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 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 Evaluation is enclosed (See780 CMR 3402.0) 0
Existing UseGroup(s):
I
Proposed Use Group(s):Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: 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-I 0 A-2r 0 A-2nc 0 A-30 A-40 A-50
I
B: Business 0 E: Educational 0 F: Factory F-I0 F20 H: High Hazard H-I0 H-20 H-30 H-40 H-SO I: Institutional 1-10 1-20 1-30 1-40 M: Mercantile 0I
R: Residential R-I0 R-20 R-30 R-40 S: Storage S-10 S-20 U: Utility 0I
Special Use 0 and please describe below:Special Use:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA 0 IBO
I
IIA 0 IIB 0I
IlIA 0 I1IB 0I
IV 0I
VA 0 VB 0 SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 Atrench will not be Licensed Disposal Site0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MAHistoricCommissionReviewProcess:
Not Applicable 0 IsStructure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes0 No 0 SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
J
SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner
Name (Print) No.and Street City/Town Zip Property Owner Contact Information:
-
- ----
---Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes
Name 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)
(Ifbuildingisless than35,000 cu. ft.ofenclosedspaceand! or not under ConstructionControlthencheckhere0and skipSection10.1)
10.1 Registered Professional Responsible for Construction Control
-
----
--Name (Registrant) Telephone No. e-mail address Registration Number
---Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor
Company Name:
Name of Person Responsible forConstruction License No. and Type if Applicable
---Street Address City/Town State Zip
- - -
---
----Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11: WORKERS'COMPENSATIONINSURANCEAFFIDAVIT(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? Yes0 No 0 SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor
and Materials) Total Construction Cost (from Item 6)=$ 1.Building $
Building Permit Fee=Total Construction Cost x __ (Inserthere 2. Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $
Enclose check payable to
6. Total Cost $ (contact municipality) and write check number here 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 inthis application is true and accurate to the best of my knowledge and understanding.
-
--
----Please print and signname Title Telephone No. Date
-
--Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
_
_
J
Appendixl
For demolition of structures please obtain a DEMOLITION PERMIT from the Town of Boylston
Available in the Building Department or on [email protected]
Appendix 2
Construction Documents are required for structures that must
comply with 780 CMR 116.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 (521CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation 20 Other (SpeciJy)
21 Other (Specily)
22 Other (SpeciJ'y)
*Areas ofDesign or Construction for which plans are not complete atthe time of application submittal must be identified herein. Work
so identified must not be commenced until this application has beenamended and the proposed construction document amendment has been approved by the authority having jurisdiction. Work started prior to approval may besubjected to double the original permit
fee.
Registered Professional Contact Information
-
-
---Name (Registrant) Telephone No. e-mail address Registration Number --
-Street Address City/Town State Zip Discipline Expiration Date
-
-
---Name (Registrant) Telephone No. e-mail address Registration Number
-
--Street Address City/Town State Zip Discipline Expiration Date
-
---
-Name (Registrant) Telephone No. e-mail address Registration Number --
The Commo
n
wealth
of
M
assachusetts
Department of Industrial
A
ccidents
Office of Inves
t
igation
s
600
W
ashington Street
Boston
,
.
MA
0
2
111
www.m
ass.go
v
/dia
W
orkers'
Compen
s
ation
In
surance
A
ff
i
da
v
it: Builder
s
/ContractorslElectricians/Plumber
s
Applicant Information
Please Print Legibly
Name
(Business/Organization/Individual):---
-
---
--
---Address:
_
City/State/Zip
:
Phone #:
Are you an employer? Check the appropriate box:
1.0 Iam a employer with 4. 0 Iam ageneral contractor and I
employees (full and/or part-time).* have hired thesub-contractors
2.0 Iamasole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.l
required.] 5. 0 We are a corporation and its
3.0 Iam a homeowner doing allwork officers have exercised their myself. [No workers' comp. right ofexemption perMGL insurance required.] t c. 152, §1(4), and we have no
employees. [Noworkers'
comp. insurance required.]
Type of project (required):
6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition
10.0 Electrical repairs or additions 11:0 Plumbing repairs oradditions 12.0 Roofrepairs
13.00ther _
*Any applicant that checks box#Imust also fillout thesection below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors mustsubmit anew affidavit indicating such. +Contractors thatcheck this boxmustattached anadditional sheet showing thename ofthe sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information.
Insurance Company Name: _
Policy #or Self-ins. Lic. #: Expiration Date: _
Job Site Address: City/State/Zip: _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.
Contact Person: Phone#:
I do hereby certify under thepains and penalties of perjury that the information provided above istrue and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed bycityor town official
City or Town: Permit/License # _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
