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17 SUTTON AVE - BUILDING INSPECTION (2) �5 0o CKU (ds - The Commonwealth of r�Xwv y Department of Public Safety Massachusetts State Building Code,,(,780�Cll1M1j��)CC pp Building Permit Application for any Building other t&68 vH�e- 5TK-vn-I4A Dwelling (this Section For Official Use Only) t�.., Building Permit Number: Date.Applied: I Building Official: 1 SECTION 1:LOCATI N l7 (Please indicate Block#and Lot#for locations for which a street address is not available) 7 V S 01 ! � S1 y �1/ iJ. No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check heroQlor check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other O Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No>I� Is an Independent Structural Engineering Peer Review equired7nn �+ C Yes CC❑` No�� Brief Description of Proposed Work: �l,�� ) 0'G EE>S E2 -t) SECTION 3:COMPLETE THIS 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 Group(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 applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 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 ❑ 111 ❑ IIA ❑ HBO IHA ❑ IHB ❑ I 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: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ 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-ofHazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport a roach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No! Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: t.tam TU to •0 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner - Na f1d111 �' k A o.and Street City/Town tp " errty Ownwner Contact Information: ' Jr� m z z p ma Title Telephone�No. (business) Telephone No. (cell) ij e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hereb and ski Section 10.1 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 Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Tele hone 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 application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor 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 $ A.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) 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 in this application is true and accurate to the best of my knowledge and understanding. P►��R��� _ G� RA- � 4� o ��,� EfZ V79 -2" 91 Please print and sign-name• """ e� lephone No. Date/ Street Addagss City Town to Zip J/ Municipal Inspector to fill out this section upon application approval: ' Name Date ,5e 1Z) r The Commonwealth of Massachusetts . Department of Public Safety Massachusetts State Building Code (780 CMR) i� sssb Building Permit Application to Construct, Repair, Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc. exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. " Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas (Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 S ecifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report F tin Buildin Surve /Investi ation r Conservation Re ort hitectural Access Review 521 CMRrkers Com ensation Insurance ardous Material Miti ation Documentation er Ser S eer(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address city/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zip QT'Y OF SALEM, MMSAQHUSE M BUILDING DEPARTMENT` 120WASFIINGTONSTREET,3PORom TEL. (978)745-9595 KIA4BERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING01)& ISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT., Date Job Location 2 s oi\) E <:2�, a L jj4 Home Owner Address Present Mailing Address The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official, on a form acceptable to the Building Official,that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATUR APPROVAL OF BUILDING INSPECTOR SU- TTON AVE. of a: l3.6B EXISTING 28.55` HOUSE S �*� r Lar ss t 28.80, : ADDITION 4 tV h N h WRLL i 1 1 /V 6S-O 3D U O"✓l I hucoy owWy that I hevo ezomi"d the premises and that the bwldaig W shown an this plan are hooted an the Around as shown and thot they coptormed to the mining setbacks of the Cd � OF g'.��,�Ivf �_ _ Oar1i1lYGtetl. �P,Iki0F At �^ PLOT: : P. .L JAMES r'yG ALFRED � O'VAY '. t W0.22733 '"IK CR. GiS T :-CIVIL SITES, ASSOG_,.tTIG. .. C� s`Sfana�E�aG' 349 5A L E Nl ST t VA9ZFIE4-D 7WAS C1580