83 WASHINGTON ST - BUILDING INSPECTION (2) The Commonwealth of Massach setts
l '✓, Department of Public Safety
l ✓✓✓ *�yu Massachusetts State Building Code(780 C I
Building Permit Application for any Building other than a O wo-Family Dwelli g
I - (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a'street address9s, t available)'
F�3 WgShi YlGitnYl S+. SCt 1� YY1 MA oicno t vsialhinQtonStr
No.and Street City/Town Zip Code Name of Building(t 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❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes X No Cl
Is an Independent Structural Engineering Peer R3view required? y,y Yes ❑ ❑
Brief Description of Proposed Work: P,l,li �C� �I.t-F �l r jSl.. l��T I�Ch iclnS
SECTION 3:COMPLETE THIS SECTIONIF EXISTING BUILDING:UNDERGOING RENOVATION,ADDITION,OR :
CHANGE IN USE OR OCCUPANCY . .
Check here if an Existing Building Inve tigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4.BUILDING HEIGHT AND AREA.
Existing Proposed
No. of Floors/Stories(include basement levels)8r Area Per Floor(sq.ft.) g.F�my
Total Area(sq. ft.)and Total Height(ft.) 6 381 O
SECTION 5:USE GROUP(Check as a plicable) co
A: Assembly A-1 ❑ A-2[I Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-I ❑ F2❑ H: HiMerc Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional [-1 ❑ I-2❑ 1-3❑ I-4❑ M.
antile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ I1B ❑ IIIA ❑ IIIB ❑ IV)4 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 outride 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: NIA Historic Commission Review Paxccss:
Not Applicable' Is Structure within airport a proach area? 1s their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No I Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:TRL-2-4 Use Group(s):?_� Type of Construction: t o Occupant Load per Floor: �5t7
Does the building contain an Sprinkler System?:—�Special Stipulations:
SECTION 9t. PROPERTY OWNER'AUTHOReeIZATIQN
Name and Address of Property Owner , t2Clnto 1 vt.
31 v�l�Shln tOnSt. ►2fQI+y t1C vPr�y MA. 01915
Name(Print No.and Street City/Town Zip
Property Owner Contact Information:
owner q-la q22- DOoO cr7a 423- (o34L1 �go►dberG gold
Title Telephone No.(business) Telephone No. (cell) `� e-mail addressprcr c3re•
If applicable,the property owner hereby authorizes CID
St , r M 6 ld rQ '7 k7ontoUl St beNevtj HA 01015 .
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.
Pleas SECTION 10:CONSTRUCTION CONTROL"( e, `fill out Appendix 3) �
[f buildiii is less than 3$000 cu.:ft:.:of encloseds ace and or n"of under.Constrtiction Controt then checbhere:O'and ski :Section 10.1
.. . .
10.1 Registered Professfonal Responsible for Construction Control:.`
- Name (Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor.
C,0100cra 9rcpert1CS M n n+ Inc.,
Company Name
5r�venJ oldbeM C5 -o(11�5pq_
Name of Person Responsible for Construction License No. and Type if Ap licable
1 �Zcintz�cal � t . 8 N4Clesue Mp o1g15
Street Address City/Town State Zip
lb 9 22 aLoe7.l lo3y y sno ldb erUm of erGlorcD eSre .
Telephone No. business Telephone No. cell e-mail acfdress
SECTION 11:WORKERS'COMPENSATIONINSURANCEi AFF1D.4VIT M.G.L.c.152 S,25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ S 000 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ (_, Op appropriate municipal factor)_$
3. Plumbing $ pO
I. Mechanical (HVAC) $ r)�jU Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 8(jQ (contact munfci ality)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.
5felen T. Gold�ern c)vvnor. 91B 92Z_ C6C .3 i3
Please rint and sign nam Title Telephone No. Date
h�rltflul fit-. eN rl 1 �f� nlg15
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approvals
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NILSSON+SIDIN LEGEND
ASSOCIA'IS INC. CWSM!CAL STORAGE CABINET
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262 Essex Street 15 16 Il m
Salem, MA. 01970 MOP AND HANDWASH SINK
Tel: (978) 741-5777 O
Fax: 978 741-0557 '
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City Hall,93 Washington Street,Salem,MA 01970
City Hall Annex, 120 Washington Street, Salem, MA 01970 City of Salem,
ix
To: i - A.� -V - �il� From: ` f
Pages: ?j (Including this page)
Fax: 6(7 -:zz- -7
Date: ¢/ / YJ Phone: (978)745-9595 ext.
Re: CC:
❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
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NILSS0141011 LEGEND