1 BLOCK HOUSE SQ - BPA-11-497 REMOVE/REPLACE STAIRS The Commonwealth of Massachusetts I
Department of Public Safety
I � r',% \I,Is.adwvnsS(alr Uuddmg Code l%BU C..\IR)4•venlh EJluon !
City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwelling
I fhn 1,vcium For Official L'se Unly)
liuddmg Prnmt Nurnbrr: Daly Ap)+hrJ: Budding In..,pector i
SECTION 1: LOCATION IPlease indicate Block 0 and Lot• for locations for which a street address is not available)
oiding
trrel Cm r ruwn Zip Code Name of Building pt appbcable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or chvck all Thal apply in the two rows below
wlding❑ Repair❑ Alteraliun ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Use ❑ Change of Occupancy ❑ Uthar ❑ Specify:
ng plans and/or construction documen is being supplied as pa rl of(his permitapplication? Yes ❑ Nomendent Structural Engineering Peer Review required? f Yes ❑/l�pilon of Proposed�/W/ork: MA1/P SlXt��Q ���1R eo� —�2c��
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) O
Existing Use Group(s): Proposed Use Group(s): f
Existing Hanvd Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
IVu.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sal.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F•I ❑ F2❑ H:
High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile[IR: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑
S: Storage SI ❑ S2 ❑ U: Utility❑ Special Use Cland please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 13 10 13 IIA [3 IIB ❑ IIIA ❑ 111111 IV 13 VA C) VB ❑
i
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: french Permit:
Debris Remavil:
I'ubbc❑ ( hciA tl,.0 l>rtic 19„..1 G.nc O Inahc.nr municipal❑
\french will not be I.icrmed Un)n..al�,le ❑
required Cor trench ..r .periic._
I'rlealy❑ „r unlcnbN Zuna•:_ ..nm.,tr,\drm ❑
1 prrmu ❑ _
Railroad right-of-way: Hazards to Air Navigation: \1-\ IL�e
\, I \)Id..,ddc0 L?Iru:Iwe utlhm.nrpnrl.il`l•h.dilt.irr.l' Llhcu n•+.rl+ om+1•IcIrJ, �
., l',.n-.Ill e. 14111111 cudnwJ ❑ I 1 v.❑ ..r\u❑ 7 r.O V. ❑
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SECr1U.V 8:CONTENT OF CERTIFICA fE OF OCCUPANCY
t.n,ul,1 _ fl l•c •I l•mdrm lu n, ___ llcCuF•.In11 ,..,I ivr lL „' __.__.__._._
len.Ibr bu.l,ln,q..mlem.m �Ivudlrr T, dvm` `prr�al�upuauon. _____ �
40 rc�
t
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'atne.ual .\.Idn•ns ul l'nh+crH' U+veer
_
\anm!Pool! N'u..ind Nreel I, i%, Gp I
1'n-per1s U+.ncr(-,intact Inlorm.uwn: -
Isle Tvlel+hone No. (bu..ina:n) Telephone No. (cell) v moil addre•..
II.t ,,.V,heal}Ie, the proper! ,n+ncr herebv authorizer 1' ,
L.4 fL In SWarn /�S ��Wra';(v'rru �• I P Yv�– CJ f .�j
Name Nrcet. ddrv.s* Citta Town State Lip
w act on the j,roVvrl% o+v ner'.behalf, m all matter.,relattce to work.nnhonza•d by ihi,bud.hn •pvrrnit a + +hc,rtwn.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
111 bwWm•is Ls thin 1$,Ualcu.MW vndovJ s+ace and/ur nil undue C.mntnt.hon Gmlrol then check hrre❑and kip V•Jwn 10 II
10.1.1�Re istered Professional Responsible for Construction Control
l
Name(Registrint) relephunp.Nu. a-mall address Rry�utration Number
lS7 )i.�rC(7rn�r-t C�' CXauyla.c0 Y��- �� � � C�SJ
Street Address City/Town Mate Lip Discipline apira on Date
10.2 General Contractor
cz cams I
Co vny� ame: _
?vaSQ04-S /S�alS7 +nL�I'v1'cQ ro �
Name of Persu R W' Bible for�Constr is on Li n woo and Type if Applicable
Cf l n hrvi �a/ /Y� t 3
Street Address City/Town State Zi
p
Telephone No.(bustrim) Telephone No.(cell) e-mail address
SECTION 11:WORKERTCOMPENSATION INSURANCE AFFIDAVIT IM.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of In!11:13
l Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the of the issuance of the building permit.
Is a signed Affidavit submitted with this application? es❑ No O
SECTION 12:CONSTRUCTION COSTS AND PFEE
Item Estimated Costs:(Labor
and Materials) Total Constructionfrom Item 6)=SL Building 5 Building Permit Fee= Construction Cost x (Insert here2. Electrical ' appropriaticipal factor)=S3. Plumbing 81. (Mechanical (HVAC) S Note:Minimum I nt nicipality)
5. Mechanical (OtherEnclose check payablfi. Intal Cast 5 (contact munici alit )ae check number hereSECTION l3:SIGNATURE OF BUILDING PERMIT CANT
By entering my name below, I hereby ottvsl under the pains and penalties of perjury that all of the information,, ntained in this
.rpplication to true and accurate to the bent of my knuwledgeand undvrstandmg.
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( nt: Totsn �tafr LI),
I• Municipal Iuspe for to fill out this section upon application
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