99 WASHINGTON - BUILDING INSPECTION t
The Commonwealth of Massachusetts
Ip , : Department of Public Safety
:%lassachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: •Z Building Inspector.
SECTION 1: LOCATION (Please indicate Block N and Lot p for locations for which a street address is not available)
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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 BuildinAA` Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑_ Other x Specify: R.130f `
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ "N
Is an Independent Structural Engineering Peer Review required? Yes ❑ N4—
Brief Description of Proposed Work:
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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): Y
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❑ 1 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❑
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 ❑ ILIA ❑ IIIB ❑ IV ❑ 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:
FP y. Licensed Disposal Site❑
Public❑ Check it outside Flood Zone ❑ Indicate municipal Cl A trench will not be Mf
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1'rica to ❑ or induntily Zone: or on site sts required ❑or trench or pecifv 'Off4tem ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I li,tnru CommI"i.in R,-,w,, Prow.. ✓ 37-TJ
.Not ApplicaNe ❑ \ k Structure t�ithfn airport approach area? Is their re%iety completed.'
nr C nrideitt to Build encLrsed-❑," Yes ❑ or No❑ Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: L*e Group(s): Tcpe of Construction: - Occupant Load per Floor:
Does the building containa n Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name and Address of Property Owner
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Name(Print) Nu.and Street City/Town Zip
Pruperty Otyner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name �. Street Address City/Town State Zip
to act on the propertN owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,000 cu.it.of enclosed s ace and/or not under Construction Control then check here O and skip 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
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CuA ppany Nary;,
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Name—off Person Responsible for Construction License No. and Type if Applicable iclress City/Town State Zip
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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 $ zaric C'� Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ l0,660 (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�beesst of my knowledge Lind understanding. p
Pleoeep - and>il;i am Title Telephone.No. Dale
Street Address City/Town St. p
Municipal Inspector to fill out this section upon application approval: '
Name Da to