73 WHARF ST - BACK ROOM EXPANSIONr
1
The Commonwealth of Massachusetts
Department of Public Safety
\lassachuseUS Slate Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family;Dwellin
1l \ (This Section For Official Use Only)
Building Permit Number: Date Applied: It 74, !? Building Inspector:
SECTION 1: LOCATION(Please indicate Block M and Lot fl for locations for which a street address is not available)
JP3 Wkur+S � D Sn 1p� (-) 19 7n
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 Building Repair❑ Alteration ❑ Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy 13 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes a No ❑
Is an Independent Structural Engineering Peer Review required? �^ Yes ❑ :::
No x
Brief Description of Proposed Work: v ra !' � I' D n tM
EFloors/Stories
ION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
ere if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ '
Use Group(s): Proposed Use Group(s):
Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No, 00rs/Stories(include basement levels)&Area Per Floor(sq. ft.)a (sq. ft.)and Total Height(ft.) S SECnO :USE GROUP(Check asap licable)bly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ _A-5❑- B: Business ❑F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3 ❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR I11.0 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❑
1'11 ca to❑ or indentik Zone: or on site ststem ❑ required ❑or trench or,pecity:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I lilt-rir l �nnmi,mmi R,,ir„ Pwi,—:
\ut Apphc.ible ❑ 1,Structure n ilhin airport approach area.' I, their rec ietc completed?
trt Con,ent l0 Build endo,ed Cl Yes❑ or No❑ Yes ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition ut Code: L',e Gruuplsl: Tcpe of Construction: Occupant Lund per Fleur:
Docs the building cunlain an Sprinkler S%,lem.': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ad cress of Prupe tv Owner
e
3C ass Su � w,
Name(Print) Nu.and Street City/Town Zip
Properly Owner 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 pro pert% owner's behalf, mall matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cit.ft.of enclosed s pace and/or not under Construction Control then check here❑and skip Sectiun 10.1)
10.1 Registered Professional Responsible for Construction Control
FIU-4—
Na a(Re gist ant) pr Tel phone No e-mail address Registration Number
Street Address City/Town State Zip Discipline xpimtion Date
10.2 General Contractor
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
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.§ 2506))
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 O No 0-
-SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ /(contact
�municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (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.
Please print and sign name Title Telephone.No. Date
titreet Address Cit%/Town ate Zip
Municipal Inspector to fill out this section upon application approval: e2.
amr Date
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