PERMIT AP & ROUTING SLIP PEM Lit jL
The Commonwealth of Massachusetts
Department of l�li�efs% A
Massachusetts State Bu' g C e(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
�. Building Permit Number. Date Applied: Building OfFici<-1:
.— SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not.available)
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❑ 1 Alteration ❑ 1 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 ❑ No`K
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
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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): Proposed Use Group(s):
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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ 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 13 IB ❑ IIA 0. 11B 13 IIIA ❑ IIIB ❑ I IV C3 1 VA E3 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❑ 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: NIA I listoric_Commission Review 11rocess:
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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
d ss f Pro r Owner
ame(P t) No.and Street City/Town Zip
doProperty Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
1
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding rmit application.
SECTION.10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft,of enckued s and or not under Construction Control then check here Cl and skip Section 10.1
10.1 Registered Professional Responsible for CunstructibA.Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name ^'`
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:4b')R!:'&,E0NV—FN,-,A1jM INSURAN 'APFID6 1"!' M.G.L a 152§25C(Q)
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 PERmrr FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee-Total Construction Cost x_(Insert here
Z Electrical $ appropriate municipal factor)-$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ ` Enclose check payable to qe,
7
6.Total Cost -_ -$ _ jcontact municipality)and-wdte check umber here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my none below,I hereby attest un a pains and penalties of perjury that all of the information contained in this
application is true and accurate to ty kn ledge and understanding.
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Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
s
Municipal Inspector to fill out this section upon application approval•
Name Date
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION DATE
ASSESSORS DATE
93 Washington St.
CITY CLERK DATE
93 Washington St.
PUBLIC SERVICES DATE
120 Washington S
WATERktL-'�ATE
120 Washington St.
CROSS CONNECTION &DATE
5 Jefferson Ave �1 � {� n
PLANNING �'l C/l%c_ ` DATEZ�s12 yl LQ ` vv,&L-
I
120 Washington St. /
CONSERVATIONI
120 Washington St;g��
ELECTRICAL J: DATE `-11/
48 Lafayette St
FIRE PREVENTION TDATE
29 Fort Avenue /
HEALTH[ _— DATE
120 Washington .
BUILDING INSPECTOR DATE
120 Washington St.