125 WASHINGTON ST - PER. APP 4-184 NEW RESTAURANT r '$ S i S OCD
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
J (This Section For Official Use Only)
'�. Building Permit Number: Date Applied: Building Official:
1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(� 125 WASHINGTON STREET SALEM, MA 01970
No.and Street City/Town Zip Code Name of Budding(if applicable)
' SECTION 2:PROPOSED WORK
Edition of MA State Code used 2009 If New Construction check here❑or check all that apply in the two rows below
Existing Building IN Repair 12� 1 Alteration 19 1 Addition❑ 1 Demohtion ❑ (Please fill out and submit Appendix 1)
Change of Use 19 Change of Occupancy 29 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ff No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No IX
Brief Description of Proposed Work: Renovations to treat new restaurant
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 Use Group(s): B Proposed Use Group(s):
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 ❑ A4❑ A-5❑ F B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill IIA ❑ IIB13 IIIA ❑ IIIB ❑ 1 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:
Public❑ 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 the r review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 2009 Use Group(s): A-2 Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: YES Special Stipulations:
1*3 i 0 1-, lM G C-
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and A6bVt90T6TAb ETY TRUST 56 112 JEFFERSON AVE SALEM, MA 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
ROBERT DUNHAM 978 744 5050 978 839 5050 bobd@emrdrywall.com
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 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)
E building is less than 35,000 m.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
DENNIS GRAY 978 745 4404 dennisgray@verizon.net 5185
Name(Registrant) Telephone No. a-mad address Registration Number
Architecture 08/31/17
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
GRAY ARCHITECTS, INC
Company Name
DENNIS GRAY
Name of Person Responsible for Construction License No. and Type if Applicable
9A DERBY SQUARE SALEM, MA
Street Address City/Town State Zip
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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 500,000
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x 11 (Insert here
2.Electrical $ appropriate municipal factor)=$ 5,500.
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to CITY OF SALEM
6.Total Cost $ (contact municipality)and write check number here 5666
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 ac t o the be " knowledge and understanding.
DENNIS GRAY PRESIDENT 978 745 4404 12/07/16
Please print and sign e Title Telepphone No. Date
9A DER BY SQUARE SALEM MA. 01970
Street Address City/Town / State Zip
Municipal Inspector to fill out this section upon application approval: t//f,�;,,n' "✓� �.w ���j/.
Name Date
t t
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8a edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title:
RENOVATIONS FOR NEW RESTUARNT Date: 12-07-16
Property Address: 125 WASHINGTON STREET
Project: Check one or both as applicable: U New construction XExisting Construction
Project description: RENOVATION TO CREATE NEW RESDTUARNT
DENNIS GRAY 5185 08-31-17
I MA Registration Number: Expiration date: , am a
registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design
plans,computations and specifications concerning:
[ J] Entire Project [ ] Architectural [ ] Structural [ ] Mechanical
[ ] Fire Protection [ ] Electrical [ ] Other
for the above named project and that such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,(780 CMR), and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee)shall perform the necessary professional services and be present on the
construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work,I shall submi� Construction Control Document'.
G`S.�E0.ED
J.G�Rg
Qt.���A15 HilP
Enter in the space to the right a"wet"or °No.5185
electronic signature and seal: 8 BOSTON.
3 MAS&
4(rH OF A
Phone number: 978 745 4404 I dennisgray@verizon.net
Building Official Use Only
Building Official Name: Permit No.: Date:
Trial Version 10 09 2012