BPA-17-215 INTERIOR GUT/SELECT DEMO - FIRE DAMAGE The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
1 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 Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
62 Wharf Street Salem, MA 01970 # 9 Pickering Way
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❑ Alteration ❑ Addition❑ Demolition X (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other X Specify:Interior Gut/ Select Demolition
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engmeer,%Peer Review required? Yes ❑ No
Brief Description of Proposed Work: elect interior gut of affected ceilings floors and walls due
fire darra e hat alc %- - l- c),.1thne the lar, to
better degree OT accuranc . bee bcope Sheets for details outlined.
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) 0
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.) 2 5605 2 5605
Total Area(sq.ft.)and Total Height(ft.) 2 5605 2 5605
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 IIA 0 IIB 0 IIIA O IIIB 0 IV VA 0 VB 0
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
required K or trench or specify:Wood Waste
Private pQ or indentify Zone: or on site system 11required
is enclosed❑ 85 Boston St, Everett
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable l( Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 0( Yes D( 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:
(99 / g �, ��
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Add r ss of Property Owner
Pickering Wharf Somplex,GLC Salem MA
Rockett Manag&Realty Co 57 Wharf Street Ste# 2 E 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Michael Rockett 978-740- 6990 mrockett@mrrockett.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereb authorizes
Josef Koch/Clean Joe LLC 90 Lincoln Avenue Saugus MA 01906
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)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here If and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor
Clean Joe LLC
Company Name
Josef Koch CS-108276 Construction Supervisor
Name of Person Responsible for Construction License No. and Type if Applicable
390 Lincoln Avenue Saugus M _01906
Street Address City/Town State Zip
781-231L 4949 617-240- 2702 joe@cleanjoe.com
Telephone No.(business) Telephone No. celle-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 10 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 30,000.00
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 00 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 payable to City of Salem, MA
6.Total Cost $ 30,000,00 (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.
Josef Koch CEO / Owner 617-240- 2702 03/27/2017
Please print and sign name Title Tele hgne No Date
390 Lincoln Avenue Saugus MA 906
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: [
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