96 WASHINGTON SQ E - BUILDING INSPECTION Y
The Commonwealth of MassachusetEs' ='
Department of Public Safety
.Massachusetts State Building;Code(780 C�IIZ)SePenlh Edition
i City of Salem
BuildingPermit Application for an Buildingother than a 1- or2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION Imease indicate Block M and Lot N for locations for which a street address is not available)
96 WASNINKON SQ.E SftLrM OP70
No. and Street City /Town Zip Code Name Of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Constructioncheck here❑Or check all that apply in the two rows below
EEArebuildi,ng
iti Building ❑ Repair Lvl Alteration ❑ Addition ❑ Demolition ❑ (Please fill Out and submit Appendix 1)
f Use ❑ Change Of Occupancy ❑ Other ❑ Specify:
plansand/orconstruction dOcuments being supplied as part Of this permit application? Yes--❑ NO
endent Structural Engineering Peer Review required? Yes ❑ NO
ription of Proposed Wor EP C I I c,/ X
IKQ
pU
t O I l
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 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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 R-3 ❑ R-4 ❑ SL41 rfS
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Infomation: Sewage Disposal: Trench Permit: Debris Removal:
I'uhhC❑ Check if outside Bond Zone❑ Indicate municipal ❑ \ trench will not be Licensed Disposal Site❑
PI'I cate❑ ur inderink Zone:_ or on site ivstem ❑ required ❑or trench ur.pecilN:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:� li •ri;t , unnis�im R......„ f'n r•..;
\nl Apl,lic.ilde ❑ ' I.Slrui hire�cnhut nupnrt approach area' h their rev�ctc Completed'
r l ntwnl In Budd eniln.ed ❑ Yes ❑ or.No❑ l rs ❑ \o ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
lid Won.d C ode: C.0 Gruuplsl: Itpe of on, ruc ion: l lcCupant Lund per Fluor:
Uoe1 the building;contain an Sprinkler Scstem': Special Stipulations:
$t'cw 1TVnJ ApPMA. -
'40 *WA-N
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
tit EeT Mese�e�T'o q6 NNHfNG-rW SQ 5&1--1"
Name (Print) No.and Street City/Town Lip
Properh Owner Contact Information:
Co- OWNEf2 3�
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town Slate Zip
to act on the pro pert' owner's behalf, in all matters relative to work;udhorized by this building permit a �licaliun', -, , y_SEC-TION 10.CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if building is less than 3i,LAW ni.ft.of enduscd s pace and/or not under Construction Control then check here❑and ski Section Il).l1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
rPO/U ,
CuqIGIX pan Name: G5L - : g9 319
tF�CZYDLO U S P
Name of Per wn Res onsible fur Construction License No. and Type if flpplicable
H50 l�swicw st- HRMrcTCN /7 anp7
Street Address City/Town State Z�f7RIp
-�3 2 6(ti 52VQ(L21dJ&i' 4y)ic°,r,/17/�va,�rn7
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 9 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor c Q
Item and Materials) Total Construction Cost(from Item 6) _$ ( S�'�-
1. Building $ j 5OO• W Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ 1 �1
Note: Minimum fee=$` L (contact municipality)
4. Mechanical (.VAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost I $ j(50Q.co (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.
MICNAL 52YDbOtASk1 hi L01 )Un InuL CONTPAcTOA
Pleaa• print and �i};n name Title Telephone No. Date
_g5b uaK � . HA01LT01J _�t_ o198-;?
,covet address City i To%%n State Zip
Municipal Inspector to fill out this section upon application approval:
Name Uate
F .
+ a