27 SALEM ST - BUILDING INSPECTION (2) t 1
1
The Commonwealth of Massachusetts
Department of Public Safety
.-,..� Massachusetts Slate Budding Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only) __::4
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)
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No. and Street Cih• /Torun 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 Od I Alteration ❑ Addition ❑ Demolition V(Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes . ❑ No
Is an Independent Structural Engineering Peer Review required? ))� / L 11 � Yes 11❑ Nu
Brief Description of Proposed Work: f3Prr1�7dPI 1 5�• p;06'- UNr-( Ip{'� 1lIC' KfTthcyt r-8S�h Ld/v) old s
P t 1 h n zwJ Yc f Y
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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): P
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 applicable) -
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5 p- T B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ _ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14 ❑ 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:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: P
it: E
Debris Removal:
PP Y�
Public ❑ Check if outside Flood.Zone❑ Indicate municipal ❑ At bensed Disposal Site❑
reenchecif%:
I nvate❑ nr tndenlifv Zone: ur on ate rearm ❑ peed ❑
Railroad right-of-way: Hazards to Air Navigation: n�r,,t\,dAppicable ❑ I.Strui lure rctlhm auport apprn,td.area' . lheu rev le%% cmpleted.'
I to Hudd me ln.ed ❑ Yes ❑ or No❑ 1'es ❑ ..\o ❑
SECTION 8: CONTENT OF CERTIFICA"I-E OF OCCUPANCY
F.Jition ,d G'de: UIV Gnntplll: r,peof CCunaruCtlon: Occup.rnt Lood per I Inor
ILm, 01v buddurt;iontu ur,tn Sprinkler S%.Iein SpVCial Stipulations-
SECTION 9: PROPERTY OWNER AUTHORIZATION f +
Name and Address of Pru perty Owner
2') Solar, 51 2Pat�f iffy F0 60k /�9 Ail S G-�sS�+� /`I/� oi96
Name(Print) No. and Street City/Town Zip
fProperho%%xerContadlnformation (, v G
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Title Telephone No. (business) Telephone No. (cell) a-marl address
If applicable, the property m%ner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the pro perk*,iw ner's behalf, in all matters relative to work authorized by this building permit o p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,000 nt.n.of enclosed s pace and/or nut under Construction Control then check here O 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
COG57IItne- oils y 0 >7 /
Comgg,Name:1BO CL,05
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Name of Person Res onsible or Const uction License No. and Type if Applicable
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Street Address SSZ I Qt� / 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 application7 Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 2 7 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) =$
3. Plumbing $ 0-6-6
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ D D � (contact munici alit )and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest tinder 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.
r 10, 11 )60alP5 Ou/��-�'► %�8 - Y567 9 yl�
Please n and sign nat Title •Icphune `o. U, to
- 1 rC'p 71-1`1 1Z l -/ 1 /
'Ireet Address Cityi Tot% i tote Zi p
Stunicipal Inspector to fill out this section upon application approval:
Na Uate