15 PEABODY ST - BUILDING INSPECTION (2) a
_1
t;. .Y The Commonwealth of Massachusetts
Department of Public Safety
\1a110th torts.State Bu riding Cede 1780 C\IR)Seventh Editwn
City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwelling
I This Section Fur Official Use Only)
PSECT,ON
ing Permit Number: Dote Applied: Budding Inspector:
I 1: LOCATION (Please indicate Black M and Lot N for locations for which a street address is not available)
VTCX"kA �. v a o
nd Street City /Totrn Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two ruws below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 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 19)
Is an Independent Structural Engineering Peer Review required? Yes ❑ No A
Brief Description of Proposed Work:
L V
n�rt yr tl \YvC-A� Y'-X )VA , # t
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): 1'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 O H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 Cl 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage S-I ❑ 5-2 ❑ if: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ I VA ❑ VB•❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Ivaler Supply: Flood Zmr%
Sewage Disposal:
Trench Permit: Debris Removal:
I'ubl,i❑ C hciA it,nhtd ica to mumc,)+al ❑
A trench will nut be Liiemrd Ui�pu<•tl Site❑
rt•yuucd ❑,tr trench or�pcc,ly:
- I'ri c.nv❑ „r mdcn ti 'or un �dr>t'Itrm ❑ permit o enclosed ❑
I Railroad right-of-way: s to Air tiavigation: \I:\ i�,�h•n, t .•uvnnon „❑ lhut ,nrp„n.,ppn'ath.vra' I.th"I rrt icty nnnf•Ictod'
"I to lurid"'do'cd ❑ `tv,CJ r No,❑ Sr. ❑ Cl
SECTION 8:CONTENT OF CERTIFICA TE OF OCCUPANCY
L.r l�rno p�.l: _ r,pv,n l „n.lruili„n: . Occupant l-rad l,cr l I,,,.'
1L,,. ihr Pu,IJ,nt�.,uv,t nt.tn SF.nnklrr M.lent`. `pcaal?npulauun. _
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.tmv and Address of Prolperte Owner
Name(Pr nt) No.and Street J City/Town Zip
Property Uw ner Contact Inform,ulon:
Title Telephone No.(business) Telephone No. (cell) a-mad.tddresS
If applicable, the property osc ner hereby authorize,
.Name Street Address CitY/Town State Zip
tu.ict on the ro+vrty rn.ner',behalf, m,III matters relome to work authorized by this buildin , +crmat.i •lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,LXV Cu.tt.if endoxd s ave and/or not under Construction Control then check here O and skip Settion 10.1)
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
vkkaJ
Company Name
Name of Person Reslxins41 for Construction License No. and Type Ap licable
5+. {A1�> ��v✓�n C)
Street Address City/Town i State Zip
- TnyYv ° yh 1iiA1 , v��
Tele hone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1S2.§ 2506))
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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =S
1. Building $ I Building Permit Fee=Total Construction Cost x (Insert here -
2. Electrical S appropriate municipal factor)=S
3. Plumbing $
4. Mechanical (HVAC) 5 Note:Minimum fee =S (contact municipality)
5, Mechanical (Other) 5 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
.ipplicatwn is true and accurate to the be,t of my knowledge and under<tanding. —
I'Ico.c pnnt end agn mmnv Title fvlcphone Date
�trtrt Wdrell C i";Tow ri }Late Zip
j Municipal Inspector to fill out this section upon application approval:
\ame a to
Descdplion
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