2 PARADISE RD - BUILDING INSPECTION (5) r `
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,, ;► The Commonwealth of Massachusetts
7 I, Department of Public Safety
%lassachusetls State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit A lication for any Building other than a 1-or 2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available)
"2 I' ll �17 ate_ /GAG
No.and Street CitY /Town ZipGx1e Nameof Building 01'applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building 61Repair❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering P Review re,uired? Yes ❑ No �' r
�..
Brie�scriptiun of Prop,�sed Work: �/
I
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 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
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.) r
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Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ T H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: InWtutional 1-1 ❑ I-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 100 IIA ❑ 1180 IIIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl a Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check it outside Flood Zone❑ Indicate municipal A trench will not be Licensed Dispel+al Site❑
I'ricah•❑ or uxienlile Zone: ur un.itr zcstrm ❑ required ❑or trench or.peeilc:
permit is enclosed ❑ t
Railroad right-of-way: Hazards to Air Navigation: \I,\ I lia,�ri:e,nnmi..ion Ite.h„ Pn�r,•..:
..\'ul Applicable❑ I.tit nil lure\cithm avpurt appro,uh.irra' Is their renen'c�nnplctcd.'
"I l nn1cnt lu Build cnclo.ed ❑ Yc.❑ or No Cl
1'r.❑ \u ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
---------------------
[dmnn of(-ode: C.v 0"Llp(.I: rt pe ut Comtruction: Occupant Load per HOW:
IL,c. Ihr brnldin�;conlain,tn tiprin k le,Sc.lcm.': Special Stipulations: NTJ c
/_ go-217
SECTION 9: PROPERTY OWNER AUTHORIZATION 1"
Name and Address of Pniperh•Owner �l
LEG/Yj. L7G/{� U"!`1��
Name(Print) No.and Street Cih'/Town Zip
Pro\ertc Owner Contact Information:
l � r'„yl � � L7
Title Telephone No.(business) Telephone No. (cell) e-mail address
If epp lcab,lee,the pro\erh•ocyner hereby authoriz.s
>�/GhNid/J �' i/��''�.11%!/�T
Name Street Address Cih•/Town State Zip
to act on the \ro+erh owner's behalf, in all matters relative to work authorized by this building permit a ,rlicalion.
SECTION 10:CONSTRUCTION CONTROU(I'leise fill out Appendix 2W '
(If building is less than 35,LXX)cu.It of enclosed space and/or not under Comtruction Control then check here❑and skip Section ILL II
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
Co?an Na
Cs /2?
me: 2
�1"/¢/zv �.lrlg c� f , �rcifo 3
Name of erwn Re+ln'ns�ble for Construction License No. and Type rf A plicable
St eet AddAdddr_ ss City/Town State „ ` Zip
Telephone No.(business) Telephone No.(cell) 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 signed Affidavit submitted with this application? Yes f-No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ GDP-) Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical $ oiS GGYI• appropriate municipal factor)_$
3.Plumbing $ C( .
7 7 4GGe, Note:Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
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�.),+1 sign name / -title T It-phone No. 7 Dale
street :Address Citt'i To\vn State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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