65-80 CANAL ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Department of Public Safely
Ma-achu+ells State Buildin);Code(:8O C\IR)h•een I Ed Itwn !
i
City of Salem
Building Permit A Iication for any Building other than a 1-.or 2-Family Dwelling
(rhe,lv'twn For Official Use Only) i
I/ Budahng Permit Number Date Applied: , Z2076 1 Building Inspector:
SECTION 1: LOCATION (Please indicate Blocks and Lot s for locations for which a street address i not available)
$d L�i,�asr�-fin f^��970 G i
\o.and Street Ctly /Town Zip Cute Name ut Buddi g(u apphcablr)
SECTION 2:PROPOSED WORK
It New Cunstructiun check here Our check all that apply,n the twu ruws below
-' -Exiting-BuBding epai A�Irratiun-L-] --AJditiun-0 mulitiun-:❑�-Please-hlFawl�rrtd-submit-A}+prnJi-x-I-)
Change of Use ❑ Change of Ocnl pa ncy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being'supplie.d as pan of this permit applicatiun? Yes ❑ Nu
Is an Independent Structural Engineering Peer Review required? - Yes ❑ No
Brtuf DeNCrl thin of Pruposad Work: _
T— z a T (�
Lczyistliii fe<2 3 al
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existlng Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Gruup(s): Proposed Use Group(s):
Existing Hazard Index 780CMR.34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Nu.ltf Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check asapp licable)
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B. Business E: Educational ❑
F: Facto F•I ❑ F2❑ H: HiercHazard H-1 O H•2 11H-3 ❑ H-4❑ H-S❑
1: Institutional I.1 ❑ 1-2 ❑ 1-3 C31-4❑ M: Mantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and pleas,e describe below:
r I;Peaal Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
[A C3 10 IIA EI JIB C3 IIIA ❑ -.-11180 1 IVO VA ❑ V8 13
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 Removal:
A Irench will not he Licrmed Ui�ln,.,,l pie ClI'uhba ChviA duulade FL+„I Gmv❑ Inahrete rnumapal _
. rrquueJ ❑.0 trench ..r.prate.
I'rn ate❑ ear indcnu(c Lme._ ear.m
"IV�c+tem ❑ permn ,.end -.ed ❑
1
Railroad right-of-way: Hamrds to Air\avigation: \Ls l h.r„r„ r ..,,,,u,...... a,, ,,, ;•,.
\vl \ppu,.,l•Ir❑ I L�tru.lwe-l.,Ihm.,u'p,a1.q'1`n ada.�n'.I' Lthvrt n•a icl. c.nnl•IcLJ'
.., 1 .,,•cnt nlluihl.'nJ,•.rJ ❑ ' lc.❑ , r.\u❑ lr.❑ \„ ❑
SEC"TION A:CON TENT OF CERTIFIC.\TE OF OCCUPANCY
l......i _ fl i`e.gl•n,•In,.h,m ____ l'Ciuf•,ull
' 16.r.the 1•u.Lbno,.•n Llan.m �I`rul Ater�(.k•m' `)`,'ei.d�upulaln m. - �
y
. . I
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.��]L:.ntylt�rc.. u�r+1•crlr Uw nrr
I \.ime(Print) JfCJ \'u.,ln'INFtel ^ lih, f+nvn III+
I'n+ +crlr Chs nrr C ml. Inu rm.retun:
rale relephone Nu. (business) relephone No (cell) r-rn,nl.Id,ln•..
If applicable,the propert%,nc nrr herebv.ruthurltes
Name ?t real Address City/Town Stole Zip
w act on the rzo•rely owner,behalf, m all matters relattoe it,work auth,,rjzvd by this buildin •pvrniit.t + dlc.mun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 21
(11 t'".1111119 Is los Ilan_.10)14u.n.of endo ItJ s+acv and/ur nut under Conatnuuun Ct;wml Ihvn check here O.utd-kip Ill 1)
10.1 Registered Professional Responsible for Construction Control
.x rami -�zu� r�m•u d re55 r ulraliun Number
5lrrrt Address City/Town State Zip Discipline Expirahun Odle
10.2 General Contractor -
1 �Z�13 Cs 60
N mr of Pe w n Rr:rptmsiblr for Construction License No. and Type if p licab _
�T 4
tAdd /� �3&.�ty/Tow State Zip
4 121
Telephone No.(business) Telephone No.(cell) a-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 si ned Affidavit submitted with this application? Yes[] No W'
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ Z®tf�(�
I. Building $ Building Permit Fee=Total Construction Cost x
2. Electrical f g _(Insert herr
appropriate municipal factor)=5
3. Plumbing E
/ J. Mechanical (HVAC) S Note:Minimum fee='S o fymtlnicipality)
5. Mechanical (Other) 5 L
Enclose check payable to
fi. Tnbd Cast 5 (contact munici alit )and write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering my name below. I hereby attest under the pains and penalties of per)ury that all of the in!�rmation o,ntained in this
.tpplicalwn Is true and accurate t he bis ul ms' knowledgeand undrrst.mdmti.
/27
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Nfunicipal Inspector to till out this section upon appliation approval: /a/A//0