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"PermtNumbr:
The Commonwealth of MassachusettsDepartment of Public Safetyklassachruelts State Building Gale(780C,1R)Seventh EditionCity of Salem
Permit A lication for an Buildin other than a 1-or 2-Famil Dwellin
(This Section Fur Official Use Only)
Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
.2 Ll Lt/15T�l�fA S7"
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check her ❑or check all that apply in the two rows below
Existing Building❑. Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Ckcupan, ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 15—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No fd---/
Br� •f Descri iron of Pruposyd Work: /4'�III �-{V/ TL'fj�',tf �,�31-u " III
Y s 0
A-+�/ rrn vl Fl oa� Isr,ur All" Gv�GCS r TRiMt
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): r
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❑ B: Business ❑ E: EAS
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ i
1: Institutional 1-1 ❑ I-2 ❑ 1-3❑ 1-4-❑ -M: Mercantile❑ '"` R: Residential R-l❑ R-2 R-3
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe belo
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ 111B ❑ 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:
PP Y�.
Public ±9 Clunk if Outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Private ❑ or inderI Zone or on site xa:stem ❑ required ❑or trench or.peciiv:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I,\ I li.h�rir(\muninrimj IA,I,•„ Pry,,—:
.Not Applicable❑ Is SlructUre within airport appruada area? b(heir review completed.'
"I (nnxatl to Build enclosed ❑ Yes❑ or Nn❑ Yes❑ NO ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Ldilion OI(ode: Lbr Group(>): r% +e of Construction: ) +,
. 1 l«u( tot Lund per Plnor:
Doe,lhr building;contain,in Sprinkler S Iern': Special Stipulations:
-t
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) Nu.and Street Cilc/Town Zip
ProzOpener Contact Information:
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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 perty owner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is loss than 35,1N)U Cu.ft.of enclosed space and/or not under Construction Control then check here❑and.,kip Section I0.U
10.1 Registered Professional Res onsible 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
X1 (/H BR/A,u4Cq
Co any Name:
Name V P 17b R �unsjble for Construction �f 2 � tense No. and Type if Applicablecable
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Street Address City/Town State Zip
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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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 7 D OD..— Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) . $ Note:Minimum fee=$ contacZmnicipality)
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.
6)A4,B9i.AAAcJA -77 4.el (f afruM e 57S . '(S9 o L/3
l <e print and sign name Title Telephone No. Date
bZ �A) ,AIW /i 03 s-T3
titreet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
..\ame Date