5 SCHOOL ST - UNIT 8 BPA 10-945 KITCHEN 4 t
The Commonwealth of Massachusetts
Department of Public Safety
\lasachuselia Slate Building C-ude(780 CMR)Seventh Edition
G/ City of Salem
J Buildinx Permit Application for any Building other than a I. or Z-FamilyDwellin
(rhis Srctiun Fur Official Use On v)
Building Permit Number. Date Applied: Building Inspector:
SECTION l: LOCATION (Please indicate Block Is and Lot a for locations for which a street address is not available)
7 -a Floo ,1, d� 9 S14t L--)"1 (119: O)CI,1 O
..No. and Street Cih• /Town Zip Code Name of Budding(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here 0 or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ 1 Alteration Addition ❑ 1 Drmulition 0 (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents bring supplied as part of this permit application? Yes ❑ No
Nan Independent Structural Engineering Peer Review required? Q Yes ❑ No ❑
Brief Description of Proposed Work: 1 � 00 f;L._1' ` �r h-1�/y10
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): Jr
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(It.)
SECTION St USE GROUP(Check as applicable)
A: AssemblyA-1 ❑ A-2r ❑ A-2nc❑ A-3 0 A4 0 A-5❑ B: Business 0 E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 0 H-4❑ H-5❑
I: Institutional 1-1 ❑ 1.2 0 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage SI 0 S•2 O U: Utility❑ Special Use❑and lease drscribv below:
S+rcial Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 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:
Pul+hc ❑ Chuck it outside Flixai Lune❑ Indicate municipal ❑ .\ trench will nut br Licensra) Dis)wi..d Site❑
required 0 or trench ur ,pvcife:
I'ncate❑ ur IndrntlA' Zone: ur tin.nr scstrm ❑ permit I.vnclo,ed 0
Railroad right-of-way: Hazards to Air Navigation: %I% I Into n• C ��m nu�.on It,•,i,i+ 1•n•
\tit .\pphc.dde 0 L�trotture irrthut aupurt appn aiih area' Is their reuvco cumplctvd.'
a C ai"cnt n. Build vod" a•d ❑. Yv,0 or No 0 Yes❑ \u ❑
SEC`r10N 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
IJmun t ldc. _.__— C�a•l•nnrya.i: rt pc d C,ui.tnii Unn: lkcu)+,inl Lund pa•rllnur
vo
IR4'� Iho 1•uil.luir;iunl.un,�n tipnnkler}i stem` ?i•a•clal�hpulaUuns:
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Name and Addrea.of Prol.wriv Owner
Name(Print) .No.,Ind Street Cily/Town [ap
1'ropt-riv Chvner C-onlact Information:
Title Telephone Nu. (busmen%) Telephone No. (cell) a-maul adds•..
If appltcailiv.'the_pruParty owner hereby authorizes
Name Street Address City/Town Stale Zip
to act un the me-+erty owner'+behalf, mill matter%relative to work aut 1% by this budding permu a placation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
FStreetAddress
•uddin is has thin 35,00cu.it.of vnckwsl s acc and/ur not under Corofruoion Control then check hm O and 4u Smitun 111.1)
istenr Professional Responsible for Construction Control
egistrant) - Telephone No. e-mail address Registration Number
ddress City/Town - State Zip Discipline Expiration Date
eral rContractor
yNarAC � G� 7—W2Pers�nit msibJp fear Ch(�structiun License No. d Typed Applicable
N C (Crjdress City/Town , fate Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WOR I TION INSURANCE AFFT AVIT(M.G.L c. 1S2 j 2SC(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 i uance of the building permit.
Is a signed Affidavit submitted with this application? Yes 13 No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor .
and Materials) Total Construction Cost(from Item 6)=f
1. Building f — Building Permit Fee-Total Construction Cost x_(insert here
2. Electrical f Z appropriate municipal factor)-f
3. Plumbing f p.—
4. Mechanical (HVAC) f Note:Minimum fee f (conit/a�c�tm�un'ictp t )
5. Mechanical (Other) f Enclose check payable to
6. Total Cost f 0 00 — (contact municipality)and write check number here
SECTION 1 :SIGNATURE OF BUILDING PERMIT APPLICANT
&Yxe bel , I! ebvativvt under the painsand penaltivs of perjury thatall of the information conhuned in this
my knowledge and understanding.
IZ• -f1:3'TA't/ CXA-xv L- 97S . 6
)'lean pnnt.tnd ogn name Title Ivlcphone No. Date
�Iz
?trevl .Wdre.* City/Town State tip
i Municipal Inspector to fill out this section upon application approval: 4;- 9. I'D
Name I Lne
• t
\ Ci1Y OF SM EN19 >NWSACHUSETTS
A U DM DEP.%M.TENT
120 q,.%jmv4GTON STRazr, )"ROOM
ZM. (978)745.9599
P.%x(971A 7249&M
KINISER"Y DRUCOLL TUGUASST.Ptz"A
%"YOR DIRaCrOa Of R eLIC PROPERTY/K RDLNC CO-%L\QSSlCL% A
Workers, Cofnpensstlem Insurance AlVdavit: OuildwilCOnfraeterWEleetricisnslPlYmsers
>Itnllcant Informal a■ T-•-��I'_ �7 O PleeaePrint Usibls
Vafneltrntenadra.Muanenl^+bvrAad): �)tJ17� 2- /�S%/71,�( 17f=
AJJress: 2-2 ` -A, -DC PU a-2 (-)-0
City/statrizip! rt-)4 . 01`u%w e�
Are yee to employer!Cbeea the approprhN Mae Type of proptl(regrlrea
1.❑ 1 am a cteployor with a. ❑ 1 ae a ganrd coaaaeaas awl I & ❑Now coaanta:tfoe
A"loyew(Am aadfor paFdow).• have hired the at►eansacasn 2. l am a solo pnprover airprtnaa Iia"ao rlw ameched AWOL I 7. ❑Remodeling
.hip and Irve no aefplayeso Thee aubcomfsters have t. 0 Domealidoe
.vatting for met in any calamity. +vofkrs'eoafpp,iawtesaaa 9. Q Building additioe
INo workers'coefp` insurance J. ❑ We on a ce,patsda a and it ottkoes I O.Q Eloereical repair oradditias
R4��1 haw eafadard thrir
J.❑ 1 am a hofeteowfwr doing au wont riwo a oo 11(pr N haw no I I.Q PhunbMg pepsin or add dDm
mytelf.(Me works*'cane 12.0 Reef repoire
inearMee tegfairad)r `'np, 3 . NO Mathew 1).❑Ofber
comp,indurative repieed.l
•nq y'oYor ar.rem w of nW+,f affe lw WA ae aaur IeM taaefq lady wwbea•GwwowmMim Pad►i.ilmood e.
't hw+errW+�Wife ntaee dtb frtld"i.eierly ttey s Jfiy rtt Walk aed or Mw WAMW awrtanee ewe adrh a nee allhbell Nelei+.ei
Y•.ee.ww+tw A"If drl,4, air W+e 2"W-W A-I Jwl.a .T P fky;eft dgg,
/eat ee*y/era►rAr b�ror/Ibfg wwRa*'sewpewmdre/waarswar/ir aq enprrjwa Law h nbr/a/k�art//Yg a!b
;e�«eerrw
In.ur nco Company Name:
Policy/of self•itta.Lie.Ah Expiration Data:
Job Iifs AJJrcaa: CityislatWtipr
.\"sea a cap of the worker'companatlae paWy dalentloo pop(sbewleg the poft Number and esplrMlae doft)6
Mailurs to emvm coverop a.ragvimd uadw lecdoo 2JA of MOL s. 152 can lead to the impoeWcat oferiminel penddes ofe
fine up to s I.J00.00 aed/w one-year imprita"Unerft M won as civil Panama is Or fans of a STOP WORK ORDER and a floe
.If up to 52J0.00 a Jay aysinet the violator. IN advised that a copy of this atatenume maybe rurwarded to the owce of
Inc..tj tatiune.d'tho n1A for insw3me covcralto vcnilwdiaa
/do hereby rerwfy Yn/er fha pwtas end;fgMN! -�- e�j/WI tl ey�tAN Me inf«wodee pnYi"abw is trw wad a wroes
�n•n rnrtC n - "-- t7.4L°' I)ufa• �,/slid
O/flaie/Y+e aJJa /1e Not wfrrr ere this area/i dV�Ytwpkrd br t'i7av/aWw n/�ltirt
C'iryorru+re: Yermlr/Lleenrtt__
I+wrnt.\uthortfy Icirde une1:
I iluard of Ilwlrb 1. Ilu+hllnt Drparfmanf ). otyfrows Clerk J. flectrical Infpecfor 1. Pluntb+ne Impecfol
6. Uther
i l.• ntael Peron: _ _ Phone l:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.. 1:1:�{.1JNMn.�VSr
Ott.r •xut11. �t.t..a �n
v.'t.11y/yN
conaruction Debris Disposal Aflldavit
(myuireJ lur all dcmulitiun uxl renovation work)
In accurd:uxc with the siltth edition of the State Building Code, 730 CMR section 111.3
Debris, anJ ,he provisions of MGL a 30,s,s4;
is issued with the condition that the debris resulting (loan
Building Permit M I licensed waste disposal facility as daflned by MGL e
this work shall he disposed of in a proper Y
t 11. S 150A.
The debris will be trunsportcd by:
. .`.
�j nNmr of hauler)
The debris will be disposed of in
0 '
(ss.urM of a►. sty
�—tsssl�+.■ui raesiiiyi
nature of twr""J09ticanl
�Z
,fate
r
6oA'A�1`{S�Hi1(�� �ati5 9ffi��hU�-"-
6 = HOME IMPROVEMENT CONTRACTOR
Registration: 122002 -
_ Expiration: 7/9/2010 Tr# 11
j
Type:, Individual
JOHN R. TESTAVERDE
JOHN TESTAVERDE -
-27 UNCAS RD. ��-d,.-C1-`•
GLOUCESTER, MA 01930 Administrator
Nli ssachusctts- Dcpajimcnt of Puhlic Sarcq
Board of Buildin-, Rc_ulations and StandarJs
Construction Supervisor License .
License: CS 60678
Restricted to: 00
JOHN R TESTAVERDE
27 UNCAS RD
GLOUCESTER, MA 01930
Expiration: 2t16/2011
t- nuniesioner Tr#: 11064
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