237 NORTH ST - BUILDING INSPECTION (4) r
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1 (This Section For Official Use Only) o
n Building Permit Number: Date Applied: Building Official:
�Y SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not avzle) �y
olq7d0
No.and Street City/Town Zip Code Name of Building(if applicabb
SECTION 2 PROPOSED WORK.
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rowilow
Existing Building❑ Repair❑ I Alteration ❑ Addition❑ .Demolition ❑ (Please fill out and submit Appenc tx 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
B 'ef 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 Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION4: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-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ HA ❑ [IB ❑ HIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentity required ❑or trench or specify:Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: :NM I I„t, t is Cninnu,sion Kc u m I ru ass:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
t
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 prope ty owner hereby authorizes
Name Street Address City/Town State Zip
to-act on the'"ro er owner behalf, in all matters relative to work authorized by this building permit application.
f, - SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
f budding is less thin$5,000 cu.ft.of enclosed space and/or/ not under Construction Control then check here O and ski- Section 10.1
10.1 Re istered Professional Responsible for Construction Control - -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - -
Company Name
Name of Person Responsibl for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOItKFRS'C-0MFFN5A'I'I(,N INSURANCE.AFF'IDAVl'1' M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 2 Budding Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
IX` 3. Plumbing $
d. 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
t
on is true curate to the best of my knowledge and understanding.
C�d4 �h4- ('3&' -:L4T
ue nd si n meGr�a�Atle Telephone No. Date
1L D/ `� ZDddress City/Town State Zip
Municipal Inspector to fill out this section upon application approval: (IJn` O �''✓ (�' D`
Name Date
' CITY OF SALEM, MASSACFIUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,300 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
lY Date o0, \
Job Location 25�T + 'd�(A 0e4l'— Jet c M
Home Owner Address
Present Mailing Address 7tir'1�
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF 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. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will ly with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SAI EEI }�MASSAaASE M
1 BuLvyVn�DzP
120WA9> CXWSMMFT,3MFLo0R
1hL 078 79S9S95.
Fil7C(978 740 98�6
SII�ERIZYDRiSaDI1,
WYC MouesSTYUm
DntEcrcacFpLzucpxoFmy/BumDncccmmcm
Construction Debris Diisposa/AfdW t
(required for all demolition and,.renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#i is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
i n ' ur of nt
� �Dl
Date