5 EDEN STREET - BUILDING JACKET 5 Eden St.
Commonwealth of Massachusetts
City of Salem
120 Washington St,3rd Floor Salem;MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit PERMITND. g-16.198FETO BUILD .
EE PADf $715.00
DATE ISSUED: 3/15/201
This Certifies that .
has permission to erect, alter;or demolish f: building-„ I3.EDEN_STREET Map/Lot: 330588-0
as follows: Repair/Replace REMODEL TWO KITCHENS WITH LAUNDRY HOOKUPS @ 5 EDEN ST.
E Contractor Name: LELAND HUSSEY
If} DBA:
1 Contractor License No: CS-032197 x
i 3/15/2018
i Building Official Date
, t
t
This permit shall be deemed abandoned and invalid unless the work authorized by thispermitis commenced within siLtis after issuance,The Building Official
may grant one or more extensions not to exceedsix months each upon written request. ,
9
Ii All work authorized by this permit shall:conform to the approved application and the approved construction documents for witkh this permithas been granted.'
P
AN construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws�and codes.
f I t 1C
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public Inspection for the entire duration of the -
work until the completion of the same.
The Certificate of Occupancy will not issued until all applicable signatures by the Building and Fire Officials-are provided on this permit. - x
HIC#: -101743 - 'P irsons contracting with unregistered contractors do not have access to the guaran/fund-(as set forth In MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
1816JUL 21 P 340
John M. "Marty"Amberg&Susan Yochelson
5 Eden Street
Salem, MA 01970
July 20, 2016
Thomas St. Pierre, Director
Inspectional Services, City of Salem
120 Washington Street, 3`d Floor
Salem, MA 01970
Dear Mr. St. Pierre,
Please substitute Leland M. Hussey for Daniel Beauvais as the contractor listed on the
building permit issued for renovations to 3 Eden Street, Salem, MA. Mr. Beauvais has
been incarcerated and is unable to finish the job.
Mr. Hussey's contact information is 781-593-6630, husseycontracting@yahoo.com.
Thank you so much. If there are questions, please contact Marty Amberg at 978-821-1309.
Sincerely,
�0Ck"L,
Susan Yochelson
978-821-3212
Cc: Leland Hussey, Michael Lutrzykowski
Commonwealth of Massachusetts
d Citv of Salem
: i
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. 8-16-198 PERMIT TO BUILD
FEE PAID: $715.00
DATE ISSUED: 3/15/2016
This certifies that AMBERG JOHN M YOCHELSON SUSAN
has permission to erect, alter, or demolish a building.. .. 3.EDEN,.STREET Map/Lot: 330588-0
as follows: Repair/Replace REMODEL TWO KITCHENSWITH-LAUNDRY`HOOKUPS @ 5 EDEN ST.
Contractor Name: DANIEL BEAUVAIS
DBA: BEAUVAIS BUILDERS
Contractor License No: CS=-05321
3/15/2016
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by.this,pernit is commenced within siximonths after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon wrtiten requesi. -
All work authorized by this permit shall conform to the approved application and the approved construction dbcuments�for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning$by-lews and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire 0lficials are,piovkled ort ltiispermit.
HIC#: 164886 'Persons contracting Wth,unregistered'contractors do not haw 4cces3`to the guaranty fund"(asset forth in MGL c.1 42A).
Restrictions:
Building plans are to be available on site.
Ali Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
Citv of Salem �-
n m 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-16-267 PERMIT TO BUILD
FEE PAID: $374.00
DATE ISSUED: 3/30/2016
This certifies that AMBERG JOHN M YOCHELSON SUSAN
has permission to erect, alter, or demolish 1 a_building_3 EDEN-STREET— Map/Lot: 330588-0
as follows: Renovation REMODEL 2 BATHROOMS
Contractor Name: DANIEL BEAUVAIS --
I
DBA: BEAUVAIS BUILDERS
l
Contractor License No: CS=-05321 I
r 3/30/2016
I Building Official } Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any`building and structures shall be in compliance with the local zoning by-laws and codes.
1
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. I
r /
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials,are provided on this permit.
HIC#: 164886 "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
Restrictions: i
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
�p➢N➢Ipry Commonwealth of Massachusetts ;
' 9 City of Salem
A < 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
-
Structure CITY OF SALEM BUILDING PERMIT
PERMIT TO BE POSTED IN THE WINDOW
Excavation
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final
Plumbing/Gas I
Ii
Rough:Plumbing !r
Rough:Gas
f
Final
Electrical l
Service 1\ l
Rough 't ILII
Final
I
I
Fire Department
Preliminary
I
Final
RHealth Department
Preliminary
P
Final
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NO
REQUEST FOR CRIMINAL COMPLAINT
-------------------------------
FOR BUILDING CODE VIOLATIONS
-------------------------------------
To any Justice or Clerk-Magistrate of the above-named Court:
Leo E. Tremblay City of Salem Building Department
on behalf of the Commonwealth, on oath complains that:
Thompson Realty Trust, P.O. Box 1206 Haverhilll, Mass. 01831
was and is the owner of residential premises located at
3 Eden Street '/ Sct ��-� Pt.tG,sS
On April 25, 1995, a representative of the Building Department Program
inspected said premises and determined that the dwelling did not comply with
the State Building Code,780 C.M.R. 5104.0 and Gen. L.c. 143 S 59, governing
Building Maintenance;
On June 15, 1995 pursuant to S 121.3 of the Code, the defendant was served
with a written order to comply;
On June 30, 1995 , and from day to day thereafter the defendant has failed to
comply with the order, each such day being a separate offense and a separate
and distinct count of this complaint;
all in violation of Rule and Gen. L. c. 143 S 59 , and the defendant did
so willfully, intentionally recklessly or repeatedly.
7/19/95
Date Complainant
Sworn to before the undersigned Clerk-Magistrate of this o rt.
7 a" J
Date Clerk-Mag sera
i
A
REQUEST FOR CRIMINAL COMPLAINT
--------------------------------
FOR BUILDING CODE VIOLATIONS
-------------------------------------
To any Justice or Clerk-Magistrate of the above-named Court:
Leo E. Tremblay City of Salem Building Department
on behalf of the Commonwealth, on oath complains that:
Thompson Realty Trust, P.O. Box 1206 Haverhilll, Mass. 01831
was and is the owner of residential premises located at
3 Eden Street
On April 25, 1995, a representative of the Building Department Program
inspected said premises and determined that the dwelling did not comply with
the State Building Code, 780 C.M.R. 5104.0 and Gen. L.c. 143 S 59, governing
Building Maintenance;
On June 15, 1995 pursuant to S 121.3 of the Code, the defendant was served
with a written order to comply;
On June 30, 1995 , and from day to day thereafter the defendant has failed to
comply with the order, each such day being a separate offense and a separate
and distinct count of this co laint;
all in violation of Rule an en L. c. 143 S 59 , and the defendant did
so willfully, intentionally r ck ly or repeatedly.
7/19/95
Date Complainant
Sworn to efore a unde i ned Cl -Magistrate of this Court.
Date Clerk-Magistrate
REQUEST FOR CRIMINAL COMPLAINT
FOR BUILDING CODE VIOLATIONS
To any Justice or Clerk-Magistrate of the above-named Court:
on behalf of the Commonwealth, on oath complains that:
71i/) 4? 01) Z 4 L%.
was and 'is the owner df residential premises located at
On /A r\ S 199z-, a representative of
the r ., " / a 77"1p7- i Program
inspected said premises and determined that the dwelling did not
comply with the State Building Code C.M.R. and
E.
Gen.L. c . 143 § governing
—' �
On 199 S, pursuant to § 3 of
the Code, the defendant was served with a written order to comply;
On o ,1i ">_ �0 199 , and from day to day thereafter
the defendant has failed to comply with the order, each such day
being a separate offense and a separate and distinct count of this
complaint;
all in violation of Rule and Gen.L. c. 143 § _, and the
defendant did so willfully, intentionally recklessly or repeatedly .
m
Date Complainant
Sworn to before the undersigned Clerk-Magistrate of this Court.
Date Clerk-Magistrate
Tits of Sttiem, "Httssttr4usetts
;3 p
_u
Publir i1rapertg Department
�p 1Nuilbing idepartment
(9nr t3nlem preen
500-745-9595 Ext. 300
Leo E. Tremblay
Director of Public Property
Inspector of Building
Zoning Enforcement Officer
June 15 , 1995
Thompson Realty Trust
c/o Lee Thompson & Company
P . O. Box 1206
Haverhill , Mass . 01831
RE : 3 Eden Street
To Whom it May Concern:
On April 25 , 1995"a letter was sent to you with
violations concerning the above mentioned property. A
follow up inspection was conducted and to this date the
violations have not been completed.
If this office does not see any progress within the
next fifteen ( 15 ) days , court action will be taken against
you.
Please give this office a call to update this matter
or to inform us of reasons why these violations have not
been corrected.
Thank you in advance for your anticipated cooperation
in this matter.
Sincerely, _
Leo E. Tremblay
Inspector of Build_. gs
LET: scm
cc: Dave Shea
Councillor Gaudreault, Ward 5
Certified Mail # P 921 991 744
AUMIN151 HA i IUN A14U E10-UHULIVILN I
Department of Public Safety shall be notified in writing within seven (7) working
days of any action taken under this section.
101.4 Referenced Standards: Where differences occur between provisions of this
code and referenced standards, the provisions of this code shall apply.
SECTION 102.0 ORDINARY REPAIRS
102.1 General: Except as provided in Section 113.1, a permit shall not be required
for ordinary repairs to buildings and structures.
SECTION 103.0 INSTALLATION OF SERVICE EQUIPMENT
103.1 General: When the installation, extension, alteration or repair of an
elevator, moving stairway, mechanical equipment, refrigeration, air conditioning or
ventilating apparatus, plumbing, gas piping, electric wiring, heating system or any
other equipment is specifically controlled by the provisions of this code or the
approved rules, it shall be unlawful to use such equipment until a certificate of
approval has been issued therefor by the building official or other agency having
jurisdiction.
SECTION 104.0 MAINTENANCE
104.1 General: All buildings and structures and all parts thereof, both existing and
new, shall be maintained in a safe and sanitary condition. All service equipment,
means of egress, devices and safeguards which are required by this code in a
building or structure, or which were required by a previous statute in a building or
structure, when erected, altered or repaired, shall be maintained in good working
order.
104.2 Owner responsibility: The owner, as defined in Article 2, shall be
responsible for the safe and sanitary maintenance of the building or structure and
its exitway facilities at all times, unless otherwise specifically provided in this code.
Corrected 780 CMR - Fifth Edition 1-3
Uitu Of aicm. z11tt15sUr4U5jett1i
q °= Public Prnpertu Department
+"BuilDina Department
(One t+alem preen
308-743-9395 4Ext. 380
Leo E. Tremblay
Director of Public Property
Inspector of Building
Zoning Enforcement Officer April 23 , 1995
Thompson Realty Trust
c/o Lee Thompson & Company
P.O. 30X 1206
Haverhill, Massachusetts 01831
RE: 3 Eden Street
To whom it May Concern:
Due to a complaint received through the Neighborhood Improvement
Committee hot line, I conducted an inspection of the above mentioned
property and found the following:
1. Replace broken porch rails at second floor level ( front) .
Remove and replace rotted out wood deck on all porches.
3. Rear porch carrying beams must be repaired or replaced were
required.
?lease notify this department upon receipt of this letter as to your
course of action to rectify this situation. Failure to do so will result in
legal action being taken against you.
Thank you in advance for your anticipated cooperation in this matter.
Sincerely,
Leo E. Tremblay
inspector of Buildings
LET: scm
cc: Dave Shea
:ouncillor Caudreault, '.Sard 5
Larrisa Brown
Certified Mail # P 921 991 708
121.3 Prosecution of violation: If the notice of violation is not complied with
within the time period specified in the notice, unless otherwise provided in this code,
the building official may institute the appropriate proceedings at law or in equity in
a court of competent jurisdiction to restrain, correct or abate such violation or to
require the removal or termination of the unlawful use of the building or structure
in violation of the provisions of this code or of the order or direction made pursuant
thereto.
101bJUL 21 P 340
John M. "Marty' Amberg& Susan Yochelson
5 Eden Street
Salem, MA 01970
July 20, 2016
Thomas St. Pierre, Director
Inspectional Services, City of Salem
120 Washington Street, 31d Floor
Salem, MA 01970
Dear Mr. St. Pierre,
Please substitute Leland M. Hussey for Daniel Beauvais as the contractor listed on the
building permit issued for renovations to 3 Eden Street, Salem, MA. Mr. Beauvais has
been incarcerated and is unable to finish the job.
Mr. Hussey's contact information is 781-593-6630, husseycontracting@yahoo.com.
Thank you so much. If there are questions, please contact Marty Amberg at 978-821-1309.
Sincerely,
fir- �o �
Susan Yochelson
978-821-3212
Cc: Leland Hussey, Michael Lutrzykowski
Commonwealth of Massachusetts
f City of Salem
n 't 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy -
No. B-16-198 PERMIT TO BUILD
FEEEE PAI PAID: $715.00
DATE ISSUED: 3/15/2016
This certifies that AMBERG JOHN M YOCHELSON SUSAN
has permission to erect, alter, or demolish,a building:3_EDEN_STREET� Map/Lot: 330588-0
as follows: Repair/Replace REMODEL TWO KITCHENS WITH LAUNDRY HOOKUPS @ 5 EDEN ST.
Contractor Name: DANIEL BEAUVAIS j -- -
DBA: BEAUVAIS BUILDERS ! I�
Contractor License No: CS=-05321
r l +
3/15/2016
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
w
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
] 5
i S
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. ! I
i
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
H I C#: 164886 -Persons contracting with unregistered contractors do not have access to the guaranty
fund"(as set forth in MGL c.142A).
Restrictions: I /Jf
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT
Excavation PERMIT TO BE POSTED IN THE WINDOW = x
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final k
Plumbing/Gas
t
Rough:Plumbing ,
Rough:Gas
/F
Final I
Electrical I
U
Service
f Il
Rough `
t
Final i
Fire Department i
9
Preliminary I
Final I
Health Department
Preliminary
Final
Commonwealth of Massachusetts ;
r q City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5841
Return card to Building Division for Certificate of Occupancy
Permit No. B-15-198 PERMIT TO BUILD
FEE PAID: $715.00
DATE ISSUED: 3/15/2016
This certifies that
has permission to erect, alter, or demolishi a buildingw3-EDEN-S-T-REET, Map/Lot: 330588-0
as follows: Repair/Replace REMODEL TWO KITCHENS WITH LAUNDRY HOOKUPS @ 5 EDEN ST.
Contractor Name: LELAND HUSSEY
DBA: t
Contractor License No: CS-032197
i
r
3/15/2016
1 4
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved-constriction-documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
f I
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained opens for public inspection for the entire duration of the
work until the completion of the same. I !
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials-are provided on this permit.
HIC#: 101743 "Persons contracting with unregistered contractors do not have access to the guarfan/fund"(as set forth in MGL c.142A).
Restrictions:
1
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
m Citv of Salem 19F 120 Washington Sl,3rd Floor Salem,MA01970(978)745-9595x5641Return card to Building Division for Certificate of Occupancy
bg Structure CITY OF SALEM BUILDING PERMIT
PERMIT TO BE POSTED IN THE WINDOW
Excavation °
Footing INSPECTION RECORD
Foundation
Framing
Mechanical q
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final
Plumbing/Gas
a
Rough:Plumbing �
Rough:Gas '
Final _
Electrical
Service
Rough
r r S
Final E
Fire Department _
Preliminary r
r
Final
WHealth Department
Preliminary
Final
ZN The Commonwealth of Massachusetts FOR
t Board of Building Regulations and Standards MUNICIPAL
l'I'1'
D Massachusetts State Building Code. 780 CMR. 71b edition
W Building Permit Applicatio o Co trust. Repair. Renovate Or Demolish a Revmed how,o,
O - or Tiro- mnily Duelling 1. 2(X)S
Thi P!cfiqKFor Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Comr ssioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro p�e Address: 1.2 Assessors Map & Parcel Numbers
ado n/ 'f'�L
1.to Is this an accepted street? yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage I ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply: (M.O.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public ❑ Private❑ Check if yes❑ p p" y
SECTION 2: PROPERTY OWNERSHIP[
=(Print) (/
s LQ"'7
ress Service:Telephone
SECTIO : DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0101 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'- cf' `Z,-
f f �
SECTIO 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ . Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical $
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amount: Cash AmounC
6. Total Project Cost: $ �� 11 eq U 0 Paid in Full 0 Outstanding Balance Due:
1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) C— `� b q 6 t
�/' eew n. License (Number
( Expuati--
Namc of CSL- 1 older, _ �,, /n List CSL Type(see below)
t �K
addre Type Description
-� U I Unrestricted(up to 35.000 Cu. Ft.)
c i R Restricted 1&2 Family Dwellin
St nawr 1 7(� `V1 Masonry Only
RC Residential Ruutin Coserin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning ,\ lllalll'c 11W.111dLion
D Residential Demolition
5.2 Reg�te Home Impr e t Con��c�t�or(HIC) r� 7 6 -y er
(�1/R4-/Il�
HIC Comp an NamelIo,��HIC Re istrant Nar p Registration Number
S y ✓�e. dAM&
/'7Q- —7 e'T/zL13 7SExpiration Date
Signature / Teleephone
!l i5
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 5 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in all mutters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER, OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Si ned under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"
S -7 ! 4E,
f The Commonwealth of Massachusetts
(� W
Department of Public Safety
h1assachusotts Staw Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
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 ad s is not available)
' d
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 Addition O 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes O No ❑
Is an independent Structural Engineering Peer Review re yu' e v Yes O No ❑
Brief Description of Proposed Work:.
4417 S
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
jAssembly
here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
g Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. Floors/Stories(Include basement levels)k Area Per Floor(sq. ft.)
rea(sq.ft.)and Total Height((t.)
SECTION S:USE GROUP(Check as applicable)
embly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business O E: Educational ❑o F-I❑ F2❑ H: Hi h Hazard H-1 O, H-2 O H-3 ❑ H-4❑ H-5❑itutional 1-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
age S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Use: SECTION 6:CONSTRUCTION TYPE(Check asa licable)
IB ❑ IIA ❑ 1111 ❑ IIIA ❑ IHB ❑ IV ❑ I 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❑ I j Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private D required O or trench or specify:or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way; Hazards to Air Navigation: I listoric Gnnndasion 14,ic,, Poxr•ts:
Not Applicable O Is Stmcture within airport dpproach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition u(Crnle: Use Group(s): Type of Construction: . Oca+pant Load per Flour:
Uses the building contain an Sprinkler System?: _ Special Slipudations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name�an 1 Address of Prop�rty Owner
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Name(Print) No.and Street City/Town Zip Y
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e•mad 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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.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
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N}{r�e` Re�'str�nt) 7 Telephone/No. c mail address Registration Number
s/ -7 /3
Street Address City/Town State Zip Discipline 6piration Date
10.2 General Contractor
^
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Company Name _ ]
1
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Name of Person Responsible fyr Construction
iMLicense No. and Type J�cable
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Street Address _ City/Town State Zip .
Telephone No. business Telephone No. cell a-mail address
SECTION II:WORKERS'COMPENSA I ION w9UItANC'lt ArF'IUAVII, 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 budding permit.
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding S Building Permit Fee-Total Construction Cost x_(insert here
2.Electrical $ :appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check Y+a able to
P"
6.Total Cost $ d0 (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 containedin this
application is true and accurate to the best of u ledge and understanding.
C-D
�JCnn tcl eQLA-,j C;t i
Pleu.yid gign name' �r Title ma Telephone No. Date
Street Address City/Town A State Zip
Municipal Inspector to fill out this section upon application approval• 3
Name V. e