Check Off (Below) Information That Is Submitted With Permit

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1 TOWN of BOYLSTON 221 Main St Boylston, MA / fax # 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 IECC 2009 OR ASHRAE (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

2 ~ ~ The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code (780 CMR) Seventh Edition Building Permit Application 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) If New Construction SECTION 2: PROPOSED WORK check here 0 or check all that apply in the two rows below Existing Building 0 Repair 0 I Alteration 0 I Addition 0 I 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/ or construction documents being supplied as part 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 (See 780 CMR ) 0 Existing Use Group(s): I Proposed Use Group(s): Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: No. of Floors/Stories Total Area (sq. ft.) and Total Height (ft.) SECTION 4: BUILDING HEIGHT AND AREA (include basement levels) & Area Per Floor (sq. ft.) SECTION 5: USE GROUP (Check as applicable) Existing Proposed 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 M: Mercantile 0 I R: Residential R-I0 R-20 R-30 R-40 S: Storage S-10 S-20 U: Utility 0 I Special Use 0 and please describe below: Special Use: SECTION 6: CONSTRUCTION TYPE (Check as applicable) IA 0 IBO I IIA 0 IIB 0 I IlIA 0 I1IB 0 I IV 0 I VA 0 VB 0 SECTION 7: SITE INFORMATION (refer to 780 CMR for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site 0 Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic CommissionReviewProcess: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 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:

3 J Name and Address of Property Owner SECTION 9: PROPERTY OWNER AUTHORIZATION Name (Print) No. and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) 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) (If buildingis less than 35,000 cu. ft. of enclosedspaceand! or not under ConstructionControlthen checkhere 0 and skipsection10.1) 10.1 Registered Professional Responsible for Construction Control Name (Registrant) Telephone No. address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name: Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. (business) Telephone No. (cell) address SECTION 11: WORKERS'COMPENSATIONINSURANCEAFFIDAVIT(M.G.L. c C(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 0 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 2. Electrical $ appropriate municipal factor) = $ (Insert here 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 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

4 J Appendixl For demolition of structures please obtain a DEMOLITION PERMIT from the Town of Boylston Available in the Building Department or on 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 (521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other (SpeciJy) 21 Other (Specily) 22 Other (SpeciJ'y) *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 double the original permit fee. Registered Professional Contact Information Name (Registrant) Telephone No. address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name (Registrant) Telephone No. address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name (Registrant) Telephone No. address Registration Number Street Address City/Town State Zip Discipline Expiration Date

5 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,.MA Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -- Address: _ City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. 0 I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 2.0 I am a sole 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 I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, 1(4), and we have no employees. [No workers' 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 or additions 12.0 Roofrepairs 13.00ther * Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing 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, and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $ 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or 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 6.0ther _ Contact Person: Phone#:

6 MISCELLANEOUS INFORMATION BOARD of HEALTH Septic As Built submitted YES NO N/A Number of bedrooms at start of job Number of bedrooms at completion Are there any DEED RESTRICTION by the Board of Health: YES NO (if yes please explain) CONSERVATION 1. Does Work Involve: WETLANDS, WATER SHED, WELLHEAD, CONSERVATION AREAS or 310 CMR (circle all that applies & initial) YES NO Initials: TRENCH PERMIT Pursuant to G. L. c. 82A 1 and CMR et seq. ( as amended) 1. Does Work Involve: A TRENCH OR EXCAVATION YES NO Initials: HAS A TRENCH PERMIT BEEN RECEIVED YES NO Permit # DEBRIS Disposed by At Facility As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, MGL c40, 54 requires that the debris resulting there from shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c A. I certify that I will notify the Building Official by (two months maximum) of the location of the solid waste facility where the debris resulting from the said construction activity shall be disposed of, and I shall submit the appropriate form for attachment to the Building Permit. Hours of Construction in all zoning areas are Monday- Friday 7:00 am 7:00 pm Saturday 7:00 am 5:00 pm No Work on Sunday (except by a homeowner) Section Town of Boylston Bylaw

7 NOTICE Town of Boylston Building Permit Fees New Rates Effective 4/1/2010 Commercial, Industrial, Multi Family Cost of Construction Multiplier per Square Foot is as Follows: Commercial & Industrial New Construction, Additions, Renovations, Repairs, Etc.- $100 Or Architect Cost (which ever is greater) Permit Fees are Cost of Construction X Fees as Follows: $10.00 per Thousand cost of construction Square feet times (X) $ (multiplier)= Cost of Construction (round up to nearest thousand) Times $10.00 per thousand = permit fee Minimum Permit Fee for construction $ (2 Inspections) ($100) All Permit Fees are Double if Work Starts Before Permit is Received Re-inspection Fee $50.00 Additional Inspections (per inspection) $50.00 Building Permit Replacement for Lost Permits -- $ Yearly Inspections $ Plan Review fees may apply Permits are not considered issued until: paid for, received & posted on site Any Questions Please Call Building Department at Rates Effective 4/1/2010

8 Town of Boylston Building Department Project Address: Map Parcel Proposed Project: Owner: Applicant: The applicant MAY need to contact the Town Departments below for approval. Check One N/A Approval Approval* Department Signature Date *with conditions Treasurer & Collector applies Water District Light & Power Board of Health Well Report Board of Health Septic Design # of bedrooms per septic system design Conservation Determination of Applicability: Not Required Date Issued Positive Negative DEP File # Date Recorded Book Page DCR Fire Department Trench Permit Highway dept. Permit # Mass Highway Permit # Zoning Board of Appeals Case # Variance Special Permit Other 20 day No Appeal Date Selectmen (special Permit) *Department Heads: Please attach a copy of any conditions or notes to this application Building Department ph# fax#