15 PEABODY ST - BUILDING INSPECTION 4
The Commonwealth of Massachusetts
f - Department of Public Safety
/f O \l-1Nsdch use Its State Building Code(780 CMR)Sex enih Edition
�( City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
P.wr )S Ica baGl
No. apd Sir• t City /To%vn Zip Code Name of Building(it applicable)
Q \/ 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 pp )
Change of Use ❑ Change of Occupancy O .Other ❑ Specify:
Are building plans and/ur construction documents being Supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descri tiun of Pro used Wurk: P I M ss
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): y
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
kF: Factory
Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
rea (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
mbly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: i
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA El IB ❑ IIA ❑ 118 ❑ ILIA IIIB ❑ 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:
Public❑ C hick if outside Flood Zone❑ Indicate municipal ❑ A trench mvi I not be Licensed Disposal Site❑
I'ri cale ❑ or indenlih Zunr:_ or on site sestem ❑ n•yuired ❑or trench or .peci h;
permit is enclosed ❑
Railroad right-of-waV: Hazards to Air Navigation: \l:\ IluhriC C,•inmi��i •n Hrcire Pnrr..:
..\ul \pplica ble❑ Is?II IICIIIrC rnlhin airport appmadm area' 61hcu revic,c Cnmplcicd'
r Cn mrnl lu Bruld cnro.ed ❑ Yvs
❑ sir.\'o❑ 1'rN ❑ \n ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
I[.iilinn ul COaie: L,c GkILipisl: fc-pe ut C,m>trL1Cuun: tkaipant Lurid per Flour:
Une. the UwldilIg Contain an Sprinkler S%,tem' Special Stipulations:
r
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
s �� lle✓�
Nam (Print) --- Nu. and Street Cih•/Town Lip
e
Property'Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address _
If applicable, the propertV opener hereby authorizes
Name Street Address City/Town Slate Zip
to act on the pro pert opener's behalf, mail matters relative to work authorized by this buildin 6 permit a p licatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It buildin•is less than 35,000 cu. ft.of endoscd s pace and/or not under Constriction Control then check here❑and skip Section 10.1)
10.1 Registered Professional Res onsible for Construction Control
1/ln� �e_�dG14k y�-�- lyd_
Name(Registrant) +T lephune No
e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �1
Company Name:
f�Pv)h �P1J�;le
Name of Persog Responsible for Co 'truction License No. and Type if Applicable
Street Address City/Town State Zip
751 <9�(J lid
Telephone No. (business)
Telephone No. (cell)
e-mail address
Tele ( 25C 6
SECTION 11:WORKERS'COIvII'ENSATION QJSURANCE AFFIDAVIT(M.G.L.c.152. O)
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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ appropriate municipal factor)=$
3. Plumbing $ 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 m this
application is true and accurate to the best of my knowledge and understanding.
['lease print and *ign name Title Tclefhu e .\'u. Date
Ktrevt Address Cih;ToaVn Star Zip
>1unicipal Inspector to fill out this section upon application approval: a�
III! \ame Date