31 SYMONDS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
a� \L.,.ichtswIt..State Building Code 1780 \IR)Seventh Edition
\ \ City of Salem
Building Permit Application for any Building other than a I. or Z-FamilyDwelling
(rhis Section For Official Use Only)
^` J Budding Perml Numbvr: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block s and Lot s for locations for which a street address is1 not available) a
`— r S S� ��j �m� �oNc7.O
3( � G
.No. .uad titrret Cit.v /Town Zip Caade Name of Budding(it.applicable)
SECTION 2:PROPOSED WORK
It New Con aructiun check here❑or check all that apply in the two rows below
Existing Building❑ Repair)? I Alteration O I Addition❑ Demulitiun ❑ (Please fill out and submit Appendix 1)
Change of Use O ChangeufOccupancy O 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No A
Is an Independent Structural Engineering Peer Review required? Yes 4 No $[
Brief Description of Prupaasral Work: ` V,P-
-RC-\ a J
` • m
e
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): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area Is+ft.)and Total Height(ft.) —+
SECTION St USE GROUP(Check as a licable)
A: Assembl A-1 ❑ A-2r ❑ A-2nc❑ A-3 O A4 O A-517 B: Business ❑ E: Educational ❑
F: Facto F-1 O F2❑ 1 Hi Hi Hazard H-1 ❑ H-2❑ H-3 O H-4 O H-5❑
I: Institutional 1-1 O 1-2❑ 1-3 O 1.4❑ M: Mercantile❑ R: Residential R-1❑ R-2 O R-3❑ R4❑
S: Store a S-1 ❑ S-2 O U: Utility❑ 1 Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as ap IfcableI
IA O IB ❑ HA O Ile O IIIA O Ilia O IV O 1 VA O VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 1 I1.0 for details on each item)
Water Supply Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
I'ublaa• C heck at outsadr Fhsal Gma•O Indicate municapai A trench w ut be Licen,aai Di.,Ixi,a1 Site O
n•,11 urIrench +ir,pecifv:�
I'm ate❑ ur rtadvrili c Zone: ur.m,rte,c,lem O permit i.anclu,ral ❑
Railroad right-of-way: Hazards to Air.Navigation: �I a I I+.t�•n+ a �•uuna,•o�a It.-, ,I. 1'n
Nnl \p)•hcd l+Iv.1� I.'(ruclun•tcilhua aupurt approach,ova' 1,Ihru rrrirty aunplctvd.'
•n l m,cnl 1.. Ituald vnclu,a•d CI 1-e,( ar Nn D Yr,❑ �.+ O
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I .boon •d l'• Ja•. ___ L,v l.ruupl,a: rt pv ul Cmi,lrucuun: Occupant LnaJ per I lour
16y, �ha•l•udJup;:nnl.nn.m Sprinkler yt,Icm` �pa•caal�Upulauunv
SECTION 9: PROPERTY OWNER AUTHORIZATION I
.Namv and .\.Idrrss al 1'ropvrty Owner
Name(Print) .No. and Strcel Cih./ rown zip
1'r j.,erty 0%%nvr Contact InWrmatnm:
Title Trlrphune Nu. (buxmvss) Telephone No. (cell) a-mad addre�s
If opphcablr, the pruperm owner hereby authorizes
Name Street Address City/Town State Zip
to act on the .ro lerty owner's behalf, m all matters rulain v to work authorized by this building permit a • lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If l•uddin is let. than 14,00cu.n.of vndosccl s ace anJ/ur nut under Cora-friction ConWl then check hen O and Aup Scc9wn 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
102General Contractor
.21 RraC- l(ZU I.-,:I 11. c
CoFs�&ny rip //` Csale k7Jc,Cfr-6VL0 CC 9463,()
Nam u �
( r Rrspu rible fur Cunslructiun (ylcrnse No. and Type iI licable
41C �eaJc.� fin iPlf� _ �
Srrbi}rt1q961 rang Ih R`4� City/Town State Zip
Telephone No.(business) ra tTele hone No. cell e-mail address
SECTION 11:WO V (M.G.L.c. 1SL J 2SC(6))
A Worker'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 ipuance of the building permit.
Is a si ned Affidavit submitted with this application? Yes er No O
SECTION 12.•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)-f
1. Building Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor) f
pechan
bing f
anical (HVAC) f Note:Minimum fee=• (contact municipality)
nical (Other) f Enckiw check payable to
Cost f 3� �"�O (contact munici alit )and write check number here
SECTION 17:SIGNATURE OF BUILDING PERMIT APPLICANT
ng my name below, 1 hereby attest under the pans and penalties of perjury that•dl of the infurmatum contained in this
on is true andaccurate to theb"I of mmy kkno vIvigrand unndervtandding.1/° lna •n name p ria relc•phone.Xo. Uate
ytzn
Struve Addre, —T CrtsiTown tat zip
Municipal Inspector to fill out this section upon application approval:
No ate