212 WASHINGTON STREET - RILEY PLAZA EAST - BUILDING INSPECTION ' SupErfiab.
90% h-F Von
/// 1 9mEAO
KEEPING YOU ORGANIZED
No. 10301
. WIMBnr
�_� rae►caa.B
V"Wum
OETORGAMM V%FADVW
Commonwealth of Massachusetts
f _
City of Salem
" 9 Inspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Application For Building Permit (For Buildings other than a One- or Two-Family Dwelling)
(This Section for Official Use Only)
PIN: TB-16-1077 Date Applied: 9/21/2016
Building Official(Print name):
SECTION 1: SITE LOCATION(Please Indicate Block#and Lot#for locations for which a street address is not available)
212 WASHINGTON STREET , Salem, MA
SECTION 2: PROPOSED WORK
Are Building plans and/or construction documents being supplied as part of this permit application?: No
Is an Independent Structural Engineering Peer Review Required? Yes[—] No❑
Brief Description of Proposed work: At Riley Plaza Newstand:
INSTALL PLYWOOD ROOFING
permit rejected by T StPierre -City owns property not applicant. Mr. Padovani notified. He applied for a sign
permit(a-frame)#6-16-
1188.
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 34))
Existing Use Group: Proposed Use Group:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(Include basement levels)&Area Per Floor(sq.ft.) 0 1 0.00 0 0.00
Total Area(sq. ft.)and Total Height(ft.) 0.00 1 0.00 0.00 0.00
SECTION 5: USE GROUP
SECTION 6: CONSTRUCTION TYPE
Town Consery
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 inside Flood ZoneE] Municipal will not required E:] Licensed Disposal Site ❑
or or
Identify Zone: Is enclosed ❑ or specify:
Railroad right-of-way: Hazards to Air Navigation: IMA Historic commission Report Process:
Not applicable
El Structure Within airport approach area? Yes Is their review completed?
or
or Constant to Build Enclosed ElYes [:] No ❑ El No
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
THIS IS NOT A PERMIT
"°T+ Commonwealth of Massachusetts Est\
upw City of Salem
Inspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Edition of Code: Use Group(s): Type of Construction:
Occupant Load per Floor Does the building contain a sprinkler system?:#Error
Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
SALEM CITY OF RILEY PLAZA SALEM MA 01970
If applicable,the property owner hereby authorizes
MB INSTALLATION 47 OVERLOOK RD MARBLEHEAD MA 01945
To act on the property owner's behalf,in all matters relative to the 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 skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name Phone Email Registration Number
Address Discipline Expiration
Date
10.2 General Contractor
Company Name
License no. and License Type if Applicable
Name of Person Responsible for Construction
Address:
Phone Email Address
SECTION 11: WORKER'S 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?
SECTION 12: CONSTRUCTION COST AND PERMIT FEE
Total Estimated Costs(Labor and Materials): $0.00 1 Building Permit Fee: $25.00
Enclose check payable to the City of Salem, Ck#
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.
THIS IS NOT A PERMIT
°"°"�� Commonwealth of Massachusetts E
City of Salem t
9 Inspectional Services
R 99LPTJ
120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Please print and sign name Title Telephone
Address: 47 OVERLOOK RD MARBLEHEA MA 01945 Date: 9/21/2016
D
Municipal Inspector to fill out this section upon application approval: 9/21/2016
Name Date
THIS IS NOT A PERMIT _�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of F perty Owner /
if.�lC110 i9D0y�9�1/ �� ��Ri9aPh Sf � 5 J%�lPl�yJ owe)
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: c�
Title Telephone No. (business) Telephone No. (cell) e-mail address � V
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 building permit application.
SECTIOiN 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 0 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
10.2 General Contractor
I -��1L1 mk_ tVVV_ D
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:W0RKER9'C'OMP1N15A'f1ON INSUPANC..E APPIDAVIT M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the NIA 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 0 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 $
d. Nlechanicat (HVAC) $ Note: Minimum fee=$ (contact numicipality)
5. Mechanical Other $
Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Al
By entering in ame e , I herebyRattest5ider he ains and penalties of perjury that all of the information contained in this
applicatio ue d c urate to thn ledge and understanding.
t' er
Please p nt m i sign name Title "Ce(ephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
2L
The Commonwealth of Massachusetts
Department of Public Safety
r Massachusetts State Building Code(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 Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street add ess is not available)
13(LOf tntaVlsr- C5+1 M&otito- nc✓ossa t1IKYClt. sNkna)5pft�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
J Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ TDemolition ❑ (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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
Al
SECTION 3:COMPLETE THIS SECTION IF EXISTING BU I UNDERGOIN VATION,ADDITION,OR
CHANGE IN sl�aR OCCUPANCY
Check here if an Existing Building Investigation nti tion is e ncl d(See 7$tv R 34) ❑
.fiVExisting Use Group(s): ropo e Use Group(s):
C ON 4:BU L NG HEIG D AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per1F q. 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 ❑ t\-4❑ A-5❑7 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 CI ht-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ 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 IB ❑ IIA ❑ FIB 13 IIIA ❑ 11111 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 730 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 ❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: Nita Historic Cominismon.Rcvin�Procc_ss:
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 Gtnup(s): 'rypeofConstructiow Occupant Load per Floor:
Does the building contain an Sprinkler Svstem?: Special Stipulations:
`r" Ak s tn.V . (Z4EVL4::sc-iED fit\ Si6f`s f'r_--P_m*'T U--1b-It S