81 WASHINGTON ST - BUILDING INSPECTION (3) CEIVED
The Commonwealth of MaSsachlf WTI"
Department of Public Safety f�
Massachusetts State Building Code(780 CMR) (tIIJ M�Y 2 0 A ID 0 2
Building Permit Application for any Building other than a One-or wo-Family Dwelling
- (This Section For Official Use Only)
I Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
l 81 Washington Street Salem 01970
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration Q§ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are buildingplans and/or construction p / t on documents being supplied as part of this permit application? Yes 11 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No H
Brief Description of Proposed Work: Expanse existing tenant's offices to next adjacent
suite 210. Reconfigure severai interior waiis, rep ace ex _ ca
counter too and backsplash with new and create pus pass— roug
sire 211 to suite 210
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION;ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing UseGroup(s): us ness Proposed UseGroup(s): _ huclne
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business D E: Educational ❑
F: Facto F-1❑ F2❑ I H: HAP Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-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 ❑ 1 HA ❑ IIB ❑ HIA ❑ IIIB D IV ❑ VA ❑ VB 13
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 11 Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not.Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
Sir U.C. . tp ($
' SECTION 9: PROPERTY OWNER AUTHORIZATION
it Name and Address of Property Owner
81 Washington St. RE, LLC 81 Washington St. Salem MA
Name(Print) No.and Street City/Town Zip 01970
' Property Owner Contact Information:
owner 978 922 0800
Title —— 978 423 6344 sgoldberg@goldbergpropertiesre.com
Telephone No. (business) Telephone No. (cell)If applicable,the property owner hereby authorizes e-mail address
Steven Goldberg 7 Rantoul St. suite 100B Beverly MA 01915
Name Street Address City/Town State Zip
to act on the property 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 buildin is less than 35,000 cu.k.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Re 'stered Professional Res onsible for Conshuction Control
Name(Registrant) - Telephone No. e-mail address
Registration Number
Street Address City/Town State
Zip Discipline Expiration Date
10.2 General Contractor
Goldberg Properties Management LLC -
Company Name
Steven Goldberg es 065097 3— 17
Name of Person Responsible for Construction - j
License No. and Type if Applicable
7 Rantoul St. suite 100B Beverly MA 01915
Street Address
978 922 0800 City/Town State Zip
_ 978 423. 6344
Tele hone No. busness sgoldher-@gQldbergpropertiesre.com
Tele hone No. cell SECTIe-mail address
A Workers'CmpensaO on In urraannce Affid�t from the MA Department off ndust IGAccidents musCbe 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 $ 31,650
2.Electrical $ 2,600 Building Permit Fee=Total Construction Cost x_(Insert here
appropriate municipal factor)_$
3.Plumbing $ 50
4.Mechanical (HVAC) $ 500 Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $
6.Total Cost Enclose check payable to
$ 36,500 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereb attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to t e es f my knowledge and understanding.
v
Please Tint d
Title Telephone No. Date
Street Address City/Town
State Zip
Municipal Inspector to fill out this section upon application approval: 41f1r-e k �
/ Name Dat
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COUNTERTOP /FILE AREA I
8Y OTHERS RLE <jCLOMgT I
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SUITE 211
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OFFICE 7
SUITE 210
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