SURF STREET - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
�'�;��„f \lessadnt.ctls Slate Budding Cade(780 CMR)Seventh Edition
—` City of Salem
B
uilding Permit Application for an Buildingother than a 1- or 2-FamilyDwelling
i -J {This Section For Official Use Onlv)
Building Permit Date Applied: Budding Inspector:
SECTION se indicate Block N and Lot N for locations for which a street address is not available)
4 ,s7- t 71 r�,c/No.and StreetTown Zip Code Name of Building(itapplicable)
SECTION 2:PROPOSED WORK
struction check here❑or checkall thatapply in the two rows below
Existing Buildinglteration ❑ Addition❑ 1 Demolition ❑ (Please fill outand submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other m'Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nq O-
Is an Independent Structural Engineering P r Review required? Yes ❑ Noy@
Brief Description of Proposed Work: O /- - �h
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): f
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 applivable)
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 C 1 H: High Hazard H-1 ❑ H-2 Cl H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-ICI R-2 Cl R-3❑ R-4 ❑
S: Storage S-1 C 5--: Q U: Utility_❑. Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IBC IIA ❑ Ira " IVIA ❑ IIIB ❑ IV Cl VA ❑ VB Cl
SECTION 7: SITE INFORMATION (refer too7/780 CMR 111.0 for details on each item)
Water Su I Flood Zone Information: Sewag�fsposa l: Trench Permit: Debris Removal:N
r'ubbc C y C heck tl�nuatdv 19t.��d Zune Indicate municipal ❑ \ trench w I not he Ltcemrd Uisp��s,il Sile❑
regturec or trench ��r.poaf%:, 04,i�A.HdQ
I'I,%. le ��r ndrnofv Zonr:_ t,r.m ato>c.trm ❑ P—r7 �'Jas�-"e C/permit a cnclo•rd ❑ �—
I Railroad right-of-way Hazards to Air.Navigation: .•ntnu.-ant Pr—,
\ot \pphaablv9 - I.'InKlure a shut aupurl oppwoch area.' 1. their IV'Iele nvni,leled'
•.r l „n.c It III lituld rnd,.�ed ❑ l r.❑ ,.r N, Sri ❑ \„ ❑ /j/A
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
ftpc,n l,m.truciwn—_ Occupantf. .id l,er l-I,.or
U.n" Ihrl,wld ta Spenai Supulaoon,'
1
• SECFION9: PROPERTY OWNER AUTHORIZATION
Naam�e andAd dr ess$11 'roperty 0 nr
/ � G p
rr We, �0S"W
Name(font) No.and Street City/' own Lip
Pro a h lhyner(-antir-t Inform ition:6/
`13�,% Siul, Tii -2!L3- 3oDl k-03. t r�Etr�comcasi�C'1`
Title Telephone No. (busmess) Telephone No. (cell) e-maul address
If applicable, the properiv owner herebv authorizes
.Nome Street Address City/Torun State Zip
to oct on the lro ert% owner',behalf, trial] matters relath'e it, work authorized by this buildin • eermlt a r +lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(11 buildin•is less than 15,000cu.it.of endusrJ s ace and/or not under ConstruQion Control then check here O and stop Section IU.q
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
,X//A 501
Company Name:
Name of Peron Responsible for Construction License No. and Type if Applicable
Street Address - City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152-4 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. to
Is a signed Affidavit submitted with this application? Yes❑ No O i
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=$ .? DO
1. Building P S
3 �� Building Permit Fee=Total Construction Cost x-�% (insert here
2. Electrical S ala A appropriate municipal factor)=8 (i 0
3. Plumbing S
4. Mechanical (HVAQ S Note: Minimum fee (contact municipality)
5. Mechanical (Other) S Enclose check payable to C, dt"yl�pry7 .
6.Total Cost is 3,000 (contact munici alit )and write check number here O
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name belmv, I herebv attest under the pains and penalties of perjury that all of the informatton contained in this
application is true and accurate to the best or my knowledge and understanding.
6 V2 - 61 yo 7 o t o
I'Ir,nc print end�tgn n title Tcl ephone \o. ate
t
<Iwvt .Wdre,, l a%,Totnt }tale zip
.S' &X9,OLI 4Uefrr �]i 4/H U3G,3��1 (2
Municipal Inspector to till out this section upon application approval: V "�"u / 11 /
Name 1)ate