133-1-2 NORTH ST - BUILDING INSPECTION Commonwealth of Massachusetts ¢UP"City of SalemInspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Edition of Code: Use Group(s): Type of Construction:
1 Occupant Load per Floor Does the building contain a sprinkler system?:#Error
Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
ONE SG,LLC 14 BORDER STREET WOBURN MA 01801
(617) 821-6642
If applicable,the property owner hereby authorizes
SEAN ANDERSON' 81 GERTRUDE STREET LYNN MA 01902
To act on the property owner's behalf,in all matters relative to the 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 than skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name Phone Email Registration Number
Address Discipline Expiration
Date
10.2 General Contractor
BIG A'S HOME IMPROVEMENT LLC
Company Name
099866 CONSTRUCTION SUPERVISOR
SEAN ANDERSON * License no. and License Type if Applicable
Name of Person Responsible for Construction
Address: 81 GERTRUDE STREET LYNN MA 01902
Phone (857) 891-2589 Email Address
SECTION 11: WORKER'S 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?True
SECTION 12: CONSTRUCTION COST AND PERMIT FEE
Total Estimated Costs(Labor and Materials): $122000.00 Building Permit Fee: $854.00
Enclose check payable to the City of Salem, Ck#
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.
(857) 891-2589
THIS IS NOT A PERMIT
T� Commonwealth of Massachusetts
t
City of Salem
Inspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Application For Building Permit (For Buildings other than a One- or Two-Family Dwelling)
t
(This Section for Official Use Only)
PIN: TB-16-461 Date Applied: 5/5/2016
.Building Official(Print name):
SECTION 1: SITE LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
133-1/2 NORTH STREET , Salem, MA
SECTION 2: PROPOSED WORK
Are Building plans and/or construction documents being supplied as part of this permit application?: No
Is an Independent Structural Engineering Peer Review Required? Yes[-] No❑
Brief Description of Proposed work: COMPLETE RENOVATION; ALL NEW ELECTRIC, PLUMBING WITH NO
STRUCTURAL CHANGES
NOTE: CONTRACTOR WITH DREW THE PERMIT. NO WORK WAS DONE AT THIS SITE. (MAY. 2016)
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 34))
Existing Use Group: Proposed Use Group:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(Include basement levels) &Area Per Floor(sq.ft.) 0 0.00 0 0.00
Total Area (sq. ft.) and Total Height (ft.) 0.00 0.00 0.00 0.00
SECTION 5: USE GROUP
SECTION 6: CONSTRUCTION TYPE
Multifamily 3+
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 Check if inside Flood Zone ❑ Municipal will not required Licensed Disposal Site
or or
Identify Zone: Is enclosed ❑ or specify:
Railroad right-of-way: Hazards to Air Navigation: MA Historic commission Report Process:
Not applicable ❑ Is Structure within airport approach area? Yes Is their review completed?
or or Constent to Build Enclosed ElYes ❑ No ElEl ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
�� THIS IS NOT A PERMIT
Commonwealth of Massachusetts 4
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3 City of Salem
Inspectional Services ul� y�
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 z5641
Please print and sign name Title Telephone
Address: 81 GERTRUDE STREET LYNN MA 01902 Date: 5/5/2016
Municipal Inspector to fill out this section upon application approval: 5/6/2016
Name Date
�� THIS IS NOT A PERMIT -�