9 OSBORNE HILL DR - BUILDING INSPECTION CO
AA
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-F y ellin
.(This Section'For Official Use'Orily)
Building Permit Number: Date Applied: ---.-Building,04icial:
tEddition
ON'L LOCA7TON -lease indicate Block# d Lots#for locations for which a street address is not available)
Street City/Town Zip Code Name of Building(if applicable)
SECTION 22 PROPOSED WORK
of MA State Code used_ If New Construction check here or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 16 No 0 am �rl
Ls an Independent Structural Engineering Peer Rev' Ye ❑ No
Brief Description of Proposed Work: rtfUG1� r) S1I1�� r@MII� �GIP��111Qa
SECTION 3:COMPLETE THIS SECTION IF'E)aSTING 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):
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) MR�2 -
A,. 7
SECTION 5:USE GROUP(Check as.apphcable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Businessonal ❑F: Facto F-I❑ F2❑ H: Hi Hazard H-1❑ H-2❑ -5❑I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R- R-4❑S: Storage S-1❑ S-2❑ U-. Utility❑- "' Special Use❑and
Special Use
SECTIONr6:CONSTRUCTION TYPE(Check`asapplicable)
IA ❑ IB ❑ HA IIB ❑ IIIA ❑ IIIB ❑ W ❑ 1 VA VB ❑
SECTION 7:SITE-INFORMATION Refer to 780 CMR-111.0 for.details on each item)
Trench Permit: Debris Removal:
Water Suppl Flood Zone Information isposal• A trench not be Licensed Disposal Site
Public Check if outside Flood Zone❑ ::::ynicipalrequired or trench orPrivate❑ or indentify Zone: stem❑ permit is enclosed❑
Railroad tight-of-Way: Hazards to AIL Navigation: MA 19is[oric Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? is thew review comple ?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No
SECTION 8:CONTENT OF:CERTIFICATE OF OCCUPANCY
F
ition of Code: $ Use Group(s): Typeof Construction - Occupant Load per Floor:
oes the building contain an Sprinkler System.: WO Special Stipulations:
SECTION-9: PROPERTY OWNER AVIT30RIZATION.
Name rdAddress Property Owner 1*n elA M-A
Name(Print) T No.and Street C' /Town— Q4�Zip�
F.roverty Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail achims
If applicable,the proper[ owner hereby authorizes �n A
P O PbX 780 fi% 01m' b
Name Street Address ty/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:CONSTRUCMON'CONTROL(Please:fill.out Appendix 2)'
building is les than 35,000 cu.ft of enclosed ace and/or not under Construction Controbtben.check here O and skip Section 10.1
10.1 Registered Professional Responsible,for Construction Control
Thin -18aae. _ Z& 34 `tr9a r
me a ant Tele hone No(, mail a Registration Number
Street Address Cityr.4Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
41 111 1�iRr' S CS 271�+r1 eor)5 = 0L).!' Mrs SDC
,Name of Per n Responsible for Construction Lic ns No. and Type if Applicable
® jox # 78O MlTT _01q
Street Address ity/Town State Zip
447 Tele hone No.(business) Tele hone No. cellI e-mail address
SECTION 11:WORKERS'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 si ed Affidavit submitted with this application? Yes❑ No ❑
sECTION:12:CONSTRU&10.14 COSTS AND PERMff FEE:
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ id appropriate municipal factor)=$
3.Plumbing $ D�
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $ 11
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 here ttest under th m
and penalties of perjury that all of the information contained in this
application is true and accurate bes of kn ge and understanding.
Please print and si O'.H.R.�. ` Ti e� __ „ „Telephone No. Date
Street Address Cit3 Town �Shate --/1+�ZJiippQ(-L-�t
Municipal Inspector to fill out this section upon.application:approval:.
NameDate
IE ft�l}may .�tva��F
Professional Land.Syrveyorsm Er dvwl Engineers
ESSEX SURVEY SERVICE 1'958 1986
OSBORN PlALMER' 1911 19]Q :
BRAOFORD & WEED 1885 - 19 2
F
LOCATED IN
SA e17 MASS.
ION( S)046 /L
113.�0
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�LS/�o12�t �'/CC • �i�i1/L--
I hereby certify to the S�tL
Building Inspector that the pro-
ZONE: 91 LOT AREA: 1WVZ-- LOT FRONTAGE: hG� posed construction shown conforms
to the dimensional zoning of
FRONT YARD: I5rr SIDE YARD: le,-" REAR YARD: 30€- SAZ&9v Mass.
SCALE:
DAM JuVt ZU13 cy
, -p - �;_o CHRISTDRHER G�
REFERENCE: PL SIC 7r-z PG Christopher R. Mel d PLS n 17 y k
104 LOWELL STREET
PEABODY, MASS.01960 ` y7
(978)531-8121
rev.107W d01_coon
1,
Aw
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION TE
ASSESSORS DATE
93 Washington St.
CIT� aMERK:r,'
a
r 1 -:Pr
9° Yasliirlgto« n t. '
PUBLIC VICE DATE Al
120 Wash ig n
WATER DATE 6 (�
120 Washington St.
CROSS CONNECTION DATE ly 13 Ma ✓n '� Sh 1}
5 Jefferson Ave s
PLANNING� - _DATE (sue /`
120 Washington St.
CONSERVATION BTU Gr
120 Washington St.
t
N LE CTRICAL .rr !iti,`. S Gtthi+:� Ri1sE r^ ` ,`:u
_..-��=r��
FIRE PREVENTION _ DATE 6 /7 /
29 Fort Avenue
m,.
E.aN?L „gh��',','aa'�wM�1�=:.r�°.,
tz20'�Wasfington Sf:�� �'�`'
BUILDING INSPECTOR DATE
120 Washington St.