31 SYMONDS ST - BUILDING INSPECTION ,, ►: The Commonwealth of Massachusetts
Department of Public Safety
.\ta.sachuNvit,State Budding Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for aLny Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (PPllease indicate Block 0 and Lot N for locations for which a street address is not available)
1
No.and Street City /Town 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 er— Repair Alteration O Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
ChangeofUse ❑ 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 Work:erin w�Rrvi.Review rr.�uire�? I^� ��'A, yes ❑ No I
Brief Description of Proposed Work: wtC �LCi(.�/� tVa�r liy�yy�n/V\ Yam- Q y1—,� )I
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 a licable) _
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ 1 E: Educational ❑
F: Facto - - H74❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ I4❑ 1 R. Residential R-1❑ R-2 R-3❑ R-4❑
S: Storage 5-1 ❑ S-2 ❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ too IIA ❑ IIB ❑ IIIA ❑ 1118 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❑
or,pcnlm:
I'rrrah•❑ or umdenlile Zone: required ❑or trench
o" r on site st,trm ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air.Navigation: \I.\ I fi,l,1nr( ..i....,inn Ito,;r,. I•r „r,.;
\ot \pphcable ❑ 1,Struclu rc mthm airport approach area.' Is their rev tee, C, 1npletcd'
1-1 ("1-n,enl to Budd enClo,ed ❑ - Ye.❑ or No❑ Yes❑ \n ❑
SECTION 8: CONTENT OF CERTIFICA"fE OF OCCUPANCY
I idrtinn �d Glde: L,e Gruui+l,l: it pe of CumtruQwn: Occupant Load per Floor:
1)nv, the building Contain an Sprinkler Special Stipulations: /
SECTION 9: PROPERTY OWNER AUTHORIZATION
11x�yl rr. Pn:F v� C)w�nlr,L
Name(Print) No.Ynd Street Cite/Town ZAP `
Property lhcn}•r C rat wt Information:
aA [, M 9,7g -as- 01�C)3 _ - -
Tit a Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
it,act on the property owner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is Tess than 35,0itO cu. ft.of endoscd s pace and/or not under Construction Control then check here D and skip Section I0.1)
10.1 Registered Professional Responsible for Construction Control /jr)S'r/ia ' e6 I
t
Ea aRC(�ap
Name(Reg e-mail. dress Registration Number
MD fw _ l��_ 4 C n6v
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
CM Naqne.0
Name Person
esp.msi Ir(usCy un eNo. and Type i Ap licable
� i L
�_115�
Street Address City/To? t to ip
XL-�4- 1'71, !21 - u'Q
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 application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor Y
and Materials) Total Construction Cost(from Item 6) _$ Of
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) _$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact unicip tNy)
5. Mechanical (Other) $ A/I " 0
Enclose check payable to
6. Total Cost $ (�-W (contact munici alit )and write check number here
i S ION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By ep.te g my n•� ••b'rl. i'hr attest trader the pains and penalties of perjury that all of the information contaJinttl;,
. pplication is trur`anc "icc�t a best ut my knowled and understanding.
U
I'Ie.i.c p an . i};ti me �_ jitlr Tclephi;�nr.
1 YVIt/�l� G
titrrrl :1d'lress Cih iTotyn tote Zip
Municipal Inspector to fill out this section upon application approval:
Name I)atr
iVlnssachusetts- Department of Public Si fet
Board of Buildim_ Regulations and Standards
Construction Supervisor License
.License: CS 64393
Restricted to: 00
JOSEPHJ BOYD
321 COMMERCIAL ST
BRAINTREE, MA 02184
Expiration: 4/13t2012
t'onnnicsioncr Tr#: 21346
' � ✓axe '�amorwremeall/z o�✓ /<uaelte
Board of Building Regulations aid Standards
R
_ HOME IMPROVEMENT CONTRACTOR -
Registration: 163466
Expiration: 6/22/2011 Tr# 26575C
Type: Private Corporation
tS AAA ROYAL WINDOWS&CONSTRUCTION INC.
.JOSEPH BOYD _
321 COMMERCIAL ST. ���gwGL�.•...
BRAINTREE, MA 02184 'Wramistratur
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