8 PEABODY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
,f,.,.✓' .\lassachusclts State Building Code 0780 CAIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than A 1- or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspect,,: .
SECTION 1:LOCATION (Please indicate Block 0 and Lot N for locations for which a street address is not available)
No,and Street Cit. /To%%n Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
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)
ChengeofUse ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur constmc)ion documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineer!%• err Review required? - Yes ❑ No ❑
Brief Description of Proposed Work: \ ecT
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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.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as app licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business Cl E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hilth Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R- 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)
[A 0 too IIA ❑ 1180 IHA ❑ 11180 IV ❑ VA ❑ VB ❑ -
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:
l+ul.+ l Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Livened Disposal Site❑
required❑ortrench Ur.pecity:
I'nvate❑ or mdun Gfc Zune: or un srtr sc.trm❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air.Na vigation: ,nnn+i..ion Itrur+\ 1'n
\,d Applicable El1.StrtiCWIC\vitho\.urpurt al+pnl,tCh arr,t.' In their re%ic\c cnmpleted.'
,r 11 m.cnt to Budd enclosed ❑ 1'i•.❑ or.N.,❑ Yes ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA-rE OF OCCUPANCY
Iljown of ( ��dr: C.c la'uUpl.l: r\pe of Cun.t%Ichon: ()CCtlpant Load per I"lm,r'
I hay. the Nirldinil;conimn an Sprinkler Sr.tem.': Special SupuL\uons .
SECTION 9: PROPERTY OWNER AUTHORIZATION
N me a d .yR Addr of I'yyperty (Jw•n /
Lt Gr- a to / Off- ��/�'srt c�/97D
Name(Print) No.and Street city/Town Zip
Property the r�Contact lnlor ltwn:
SG�NiO✓ �t�,�='''IY � '8X.'E✓
Title Telephone No. (business) Telephone No. (cell) a-mad address
If a hetblr, t )roprrty utener hereby authorize r
0.
Name Sire t Address City/Town Slate Zip
to act on the-+ro erN owner's behalf, in.all matters relative to work authorized by this buildin • permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If 1•uildin•is Tess than 35.UW cu. lt.of enclosed s ace and/or nut under Construction Conuul then cherk here D and skip Section 10.0
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
Z L'� 0
C mAjpZNL
NZe of erso` pymxiblrsg Cunslructi_.u ,` - icrnse No. and Type if,Applicable
Street Address City/Town (�StateQs Z}1'��
fYGJ, +,i
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(Q)
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 D No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ CO 1
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost - - S - - (contact munici alit )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
tp licalion is true and accurate to the best of my knu ledge and Understanding.
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I 1`cp t.tnd namsL ✓ S ftle Telephone No, )ate
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Street AddreNN Citvi Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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