4 PRATT ST - BUILDING INSPECTION C-2d-o
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Officia Use Only)
Building Permit Number: Date Applied: Building Official: \
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations far which a street address is not available)
tf I`X4 (7 s% 51g uali/I lVilt C )`i7D A//+
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used If New Construction check here;❑or check all that apply in the two rows below
Eris ting Building❑ Repair❑ Alteration ❑ ;\ddition❑ Demulifion ❑ (Please fill out and submit Appendix 1)
Change Of Use ❑ I Change Of Occupancy ❑ Other Specify: RF171jA/F/l/b (MILL
r\re building phms and/or construction documents being supplied its part of tllis pertltit application? Yes ❑ No ❑
Is an hulependent Structural Engineering Peer Review reyuairred? {' Yes ❑ No ❑
Brief Descriptionof Proposed Work: Cf71-5y1" 7— /.phi ZD //�d��� �(� i��l?� �' (yf.. l/ A-1 I/q'l�/nj
�.r,/'�Ih• 1vT' /l�rlr� �iS L1r�.G, C'l� � v
SECTION 3:COMPLETE TIfIS SECTION IF EXISTING 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 Grou p(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.)
SECTION 5:USE GROUP(Check as a Iicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-a❑ 1 B: Business ❑ E: Educational ❑
F: Facto Fl ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I.1 ❑ 1-2❑ I-3❑ 1-4❑ bL• Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R4❑
S: Storage S-t ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a Iicable)
IA ❑ IB ❑ ILA ❑ IfB ❑ f1IA ❑ IIIB ❑ 1 1V ❑ 1 VA ❑ VB ❑
SECTION 7;SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y
Public❑ Check if outside Flood Zone❑ Indicate nuulicipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: Or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \Ir\I h 1 ri rinnmi 4i n I ,cic� I r:crss;
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build cndused ❑ Yes❑-or No❑ Yes❑ NO ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition Of Code:_ Use Gruup(s):. "Type Of Construction:__ Ocalpant LOad per i:l,,oe
Does the building contain an Sprinkler System?: Special Stipulations_
��� 70 Spy, S�-
SECTION 9: 1'ROPFRTY OWNER Au TIIORIZATION
Name and Addr ass of Property Owner \ �,¢ �,I2 2
S—f--+�" I/�f� ✓�f J
Name(Print) No.and StrcEt C icy/Town Zip r
Property Owner Contact Information: �7--77
17f-717 Z-12' rl 7 87—:3 iZ v
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
Of building is less than 35,000 cu.ft of enclosed s ace and or not under Construction Control then check here O and skip Section I(M)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Dale
10.2 General Contractor
Company Name ,1
Nano of Person Responsible fur Construction License No. and Type if Applicable
z L/0 11i� 5 1- ,-1 P&y LO 71%-z
Street
City/Town State Zip� Address \ —
1/Gr�)-G ���� _-_' �-. . C'`l '�t< � l�v�YY.• �• l-r2f�Fi
'role hone No. business Telephone No. cell a-mail address
SECTION 11:It LJI LI.IS'(1:1111 1.-Ny,\llc)V INSUR:\NC L_\I'1'll)AVII M.G.L.C.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be wmpleted 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 Ir9. No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6) =S
I. Building S «'�'• Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) _$
3, Plumbing $
Note: Minimum fee=:5 (contact municipality)
1. Mechanical (HVAC) $
5. Mechanicil Other $ Enclose check payable to
6.Total Cost $ �10 _ (contact municipality)and write check nuns p er here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury tha the in nrmatiom contained is this
Application is true and accurate to the best of my knowledge/arid understanding.
Please pro t and sign name Title Telephone No. Date
S 1., oilt
Street Address City/Town t:to Zip J
.Municipal inspector to fill out this section upon application approval: r '!
Nam fate
CITY OF SiuXLrI, UNSSACHUSETTS
BUILDING DEPARTSIENT
3 } ' +- y• 120 WASHL21IGTON STREET, Y'FLOOR
TEL (978)745-9595.
F.t-X(978)740-9846
KINfBER FEY DRISCOLL
MAYOR THoNfAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDIING CONLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatlon Please Print Legibly
Name(nusiix's&orpnixatiurotndividual): V,1,VI
Address:
City/State/Zip: I�Zhvri 5 /U!� UI`tZ3 Phone N: `77Y LZS -3z i2!1
,\re you an employer?Check the appropriate boat Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 b, Now construction
employees(flali and/or part-time).• have hired the sub-contractors
2.01 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have g. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. C3 Building addition
(No workers'comp:insurance 5.'❑ We are a corporation and its
�f required.) officers have exercised their 10.❑Electrical repairs or additions
J. l 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs be additions
myself.[No workers'comp. e. 1524 10J.and we have no 12,E Roof repairs
insurance required.)t employees:[No workers' 13. Other, 4l(7t hn)
comp:insurance required.)..
-Any appleum that chocks box 41 must also rill out the sectloe baiow showing liar workus'compaisatlon paltry infurmotlors.
I hHneowr ass who submit this afedevit indicting they an doing oil work and that him oVbide contmunars must submit a new attidavil indicting such
=Commcuim that chmi;this box most annhodan additional sheet showing the ran l of 1hCsubcontractors and theb workan'comp,policy intorm Lion.
f um an employer that/s provfding workers'compensation btsurancefor my empluyeet Below/s the po/fry and Job site
information.
Insurance Company Name:
Policy 4 or Self6ins. Lic. N: Expiration Date:
lob Site Address: City/State/Zip
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of b4t3L c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonmenq as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. ❑e advised that copy of this statement may be forwarded to the Of lice of
Investigutions ofthe DIA for insurance coverage verification.
Ida hereby certify rustier Mhe puAes and peso/sirs of perjury shut the brforinatiat pravided above is true and correct
y
Dard•
Phoned.
Ofjicful use ugly. Do not retire in Mile area,to be completed by city or town oflicial
City or'rown. Permit/f.lcenseti _
Issuing Authority(circlo one):
I. Board of licalth 2. Building;Department 3.Cityifown Clerk 4. Electrical htspector 5. Plumbing Inspector
6.Other
CunlactPerson: . .._ Phone it:
1 I
'v 5„
34.00' }
1'
r � I
VACANT LOT
I
I�
•.t t
1 ,501 ft.
a
Q
" 31.9$• n o ed in a tlpod hazard zone as
e ' on map #250012-6056 of
Salem', a. by the Federal Management
Agency.
S rn i t h
r MORTGAGE, INSPECTION
CAPE ANN LAND SURVEYORS, iNC.
19 TRASK STREET
Existing auiidin �N� pes► DANVERS, MA. 01923
No: 15
Hitch Street �.�wn��- �� 7hi 5 piot plan was prep`dred'n
0 9RNSy connection with a mortgage or
9 9Z25 a loan.
4�
44,2 SuB�E+
Location: Pratt St. Soiem. Mo.
Scale: 1"=10' Date: 12/29/92
References: Book 4414 page 469
2onirt ;-:R-2
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