34 WALTER ST - BUILDING INSPECTION f
r The Commonwealth of Massachusetts
\'. 1 Department of Public Safety
\I.t.,avhuwnU StatrBurlafingCodr(:80C\IR)SeventhEdittun
^ City of Salem
Building Permit Application for any Building other than a I- or Z-FamilyDwellin
(this Section For Official Use Only)
Building Permit Number: Date Applied: D Budding Inspactur:tgm
SECTION 1: LOCATION (Please indicate Block 0 and Lot s for locations for which a street ad res is not available)
39 60X-P2, 6r SA2 liEM o0A Di910
Xo. end Street Cih• /Town Zip Caafr Name of B di ( ► ably)
SECTION 2:PROPOSED WORK
If New Construction check here O or cheek all that apply in the two ruw0lelow
Existing Building O Repair❑ I Alteration O I Addition O 1 Demolition (Please fill out and submit Appendix 1)
Changeu(Usr 0 Change of Occupancy ❑ 1 Other O Specify:
_ Are building plans and/ur cunstructiun documents bring supplied as part of this permit application? Yes O No 0�
is an Indekndrnt Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed S��,
•-h�-I'Z.-ea"r.�S � 3a A�� '� �LWwLs / r�,L-.- .ct
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) O
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 Flown/Stories(include basement levels)er Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION St USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ A-3 O A4 O A-5 O 1 B. Business 0 E: Educational ❑
F: Facto F-I ❑ F2 CI H: HI Hazard H-1 O H-2 0 H-3 ❑ H4 0 H-5 O
1: Institutional 1-1 0 1.2 O 1-3 O 14/ClM: Mercantile 0 R: Residential R-10 R-2 0 R-3 O R4❑
S: Stone 5.1 ❑ S-2 0 U. Utility❑ Special Use O and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O IB 0 IIA 0 fin O IIIA 0 11111 0 1 IV C1 1 VA O VB O
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supple: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ C heck du�ls,de Pluud Luna•❑ Indicate municipal ❑ A trench will not be Llcen,ed Dispoal Site❑
I'nv.rte❑ nr rruivnbfv Zone or on,ne m,tem 0 required 0 or trench ur,pac:ic:
permit I,enclu,eal 0 _
Railroad right-of-way: Hazards to Air Navigation: \lalh•nnal,nnnn••n•nitvuvol'n•.r":
\nt :\ppbcebla•D 1,�In,clu n•r.,lhm aupurl.,pprnacherea.' I, their re%ieac cunrydcted'
C.`,•rd' m-cnl 1'. Buildvnct. 0• Iv,0 nr\oO Ye,❑ \u 0
SECTION B:CONTENT OF CERTIFICA IE OF OCCUPANCY
I ,1m,nt .4 l .-dc. L a•l ruupl,I: la pv ut ll ut,uucoun: lkcupan( I�taal pa•r lluur
16v" iho budJu+q c,vn.un en 14pnnkIvr'm,lcm` pax ial�t,pulauun,:
Co[—(�L
SECTION 9: PROPERTY OWNER AUTHORIZATION
V me and Addy s.of Pro/+a•rN• l)wnrr
r� 1� Tr- I�i G✓R3+�ft�itxJ S� &81� MA- of •
.Name(Print) No.and Street C ih,/ rown Zip
1'ruperiv 0%ner Contact Inlurmatio
n (��
Title Telephone Nu. (buanr .%) Trlephonr No. (cell) a-mad adalno. _
If app"cable, the properly owner hereby authorize+
Namr Slrerl Addrr -r. City/Town State Zip
to act on the +ro t-rti liwner',behalf, in all matters relaticv tit work authorized by this buildin +rrmit a + +hcatit, 1
SECTION 10.CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if building is lass dun 35,tW c u.it.of anckwsl s are and/ur nut under Com fructiun Control then check hem Oand,Lp Sectiun 10 1)
10.1 Re istered 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
CunyEcsR1•l�mrF Fes[C'1—/ C.
Name of Person R,,,n,iblp it structiun License No. and Type if A plicable
Idl �A)AV)NIf11VZ JI cNl'�L.� L�19
�' dr City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SEC77ON 11:W V (M.G.L.c. IS2 § 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.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor 000
and Materials) Total Construction Cost(from Item 6)=f AI
1. Building f Building Permit Fee=Total Construction Cost x_(insert here
2. Electrical f appropriate municipal factor)=f
3. Plumbingf
4. Mechanical (HVAC) f Note: Minimum fee s f (contact municipality)
5. Mechanical (Other) f
... _._ . ..- .,-,. Enclose check. payable ..to
6. Total Cyst f (contact municipality)and write check number here
ON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name bel w, I hereby oust under the pains and penalties of perlury that all of the information cnnLaned in this
.Ipplica 14 is true and accu ttr hi th br.l of my knuwlralge and understanating.
I'I�•;;.y ,nk _ot an I i •n i;IanT slapho a\u. Date
01
;Irv%q Addra" C-Il1'i T+ncn 'ate Zip
%lumcipal Inspector to fill out this section upon application approval:
Name ILne
Y Y '
,
CITY OF Sa1LE.`1, IILxSS.-%CHL;SETI'S
8C11DL�IG 10".1RT11>F.iT
120 \V.13itCVGTON STnaRTr, )"ROOM
TIEL (978)7+5-9599
P.ut(978) 7449M1
K13IaEXLEY DRI3COLL Z11 aW sr-PaULPs
.UAYOL DlaWMR Op PL aLIC?WPVATV/K ILDLVG C0-%04S310-%Es
Warkers' Compensattots Insurance AMdavih Oailders/Contractors/Eleet►IelanslPlomsers
annlleant Informatlots Please PHnt Ladsllt
Valfld(a.nw...Cr{an,.,iia//.l��.r.rer/ri--: \��.Prf� soma .c � LLB.
Addmss• �c.F_ ill�,�b� rl®t
City/Statozi� �-x� / 14 «l; I'how ? '"1 L?Z-W
F.;hip
employar!Cue&the ypopriaae be= Type of proJM(raquire4
a. ❑ 1 am a coaksrnr aed 1
unployar with • have Afro/tie arr►emlerscmn & ❑Now cosseoetfos
es(��/s Pats-tins). RetnollrlinJoin propeieearar pwr terms ❑ g
haw no employes Than s io-coneressm have s. ❑Detnolitien fer me is say capseity. voekars'comp inwrsoos 9. Q Building addition
rkats'comp. inwranee S. ❑ We as a eaapersdan an/it 10.❑EZaeetiwl repair or addition
ftvd i 1 oltlems hoes oxwcww risk
).❑ I am a homsooner doing au work riab ofeartlptiw pal,MOL 11.0 it anilbi f repairs or addkbne
mynit(Ye worbern'C011196 c. 13Z f 1(4),and we Aare no 12.Q amempoirs
inserarear regoind.)► cvv* 3 'LNG wadww� 1 13.0 aH6ar
,•r a,gaor r6r ae�aAe Gas el+,air aYe N wr rti rrrs bran awlq aW w6en'ggwwr+11
paMq ubwaaa.
'1I.Mr W w,,who water 0004"itelNWy rhq airs deM IN rleeb ad arm 1 irdlori"M&
f•..arerre rrlr cawh rW ears awrr awwdra r aYrlwwl rerwr.6•elq dw war 1ri rh•werwa old lh•L wwhw'rsT p lky 4ftr woo
/war ow eoy/rrer rAor b prorLlbtR reereeis•cosyeresadrs/wssrower/i►sqr raydryws dMme 6 rNvye/Aep ew//ki1 rfar
iw/MwrrU1M I
InruranceCompanyvalnr.S V� lS✓� ���
Ynliey e or Self-ins. Lie.N: Eapiratiee Dow.
Job Sire Addru City/JtatrZlp:
.lase&a copy of the werhen'compasaWe palky dsolonifas pop(show"the pnuey nmbw and seplretlsar deer)6
F'ailuro to aaew0 co rap al re'"'ad un.ia 1atloa 33A o!NOL Q 152 care lead ro the imposition of criminal pnalHw of a
fins up to S I.J00. and/ar one- imprisonment,as wall as civil Penalties is an fans of a STOP WORK ORDER and a floe
of up to S210.00 a ay ryaing th violator. Ile adviwrl ihm a cupy of this atstrnent maybe forwarded to Ills 0111ce of
Inccsrryariuna.drhw IAfrir lrancecovcrapvwiticaeica
/,/o horeiYy rrrN owd •pwiwa•ad pewr/dve•/0"IN7'As#'AN iw/rwodow provided w6vw 'o lr*NZASOW�wreA
O/J/iie/•,e ow//L Ao�a..riM;w die rrcq y av.wwp/rhol 6y rilJ o/uww,.//krt
City or ruvn: Yermit/Llanu 1__ _
laulat.lulhonry(circle ane):
1 IIu.rJ of Ilcaleb t. Rud d"11 Mparrmvne I. cty/rown Clerk 1. Electrical Gnpcctor !. Plumbmt Impeetor
6.rlther . —
l .of act Perron: Phone a:
*` CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,.,I: ■I r 1 •'wl�
\I .r.•w tn:v:6:J.4•lyy �I'\r.v7b, S'
construction Debris Disposal A111davit
(rL•yuimd fur all demolition :utd renovation work)
In acconlatue with the sixth edition of the state Building Code, 730 CMR $action 1
wvisiuns of MGL a . ssu
Debris.and the p _ • _ is issued with the condition that the debris resulting ttom
Ouildiou 1'I:rmit M r properly Licensed waste disposal fbcility as donned by MGL c
this work shall he disposed of in
ll1. S 150A.
The debris will be Imnsported by.
puma ul hoular)
The dcbris will be disposed of in :
IjL,--�>
Cps �(n:urleul acllty
✓�1 UVI�
I;�tnaw ul'1'�edilyl
r/it we.11lx:rnlir,tltllieaM
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