135B CANAL ST - BUILDING PERMIT APP C.;(��i
The Commonwealth of Massachusetts
Department of Public Safety
.%Lu.ochu.etts State Building;Code(780 CMR)Se%enth Edition
�\ City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(Thi,Section For Official Use Only)
Building Permit Number: Date Applied: . 0 Building Inspector:
SECTION l: LOCATION (Please indicate Block k and Lot M for locations for which a street address is not available)
x 13S" (,AN L 'j+ SALEM 011 -70 N/A
..\b.and Street Cite /Town Zip Code Name of Building (if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two ruws below
Existing Building Repair ❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Changeof Use Change u(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:
Inff
aMW
U G 5
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) ❑
Existing Use Group(s): Proposed Use Group(s): _-_- .
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly AA ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ I-4❑ M: Mercantile ❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage S-1'❑ ' •S-2 ❑ - U: Utility O 1 - -Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
[A [3 111 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV 13 1 VA VB
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
i Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y
Public❑ Check if oubide Floud Znne ❑ Indicate Municipal ❑ A trench will not be Licensed Di>posil Site❑
Pnc.mte❑ or indenlifc Zone: or tin site scstem ❑ required ❑or trench ur 1pcatc:
- permit is rnclused ❑
Railroad right-of-way: Hazards to Air Navigation:gation: \I:m Inn ni;t ,nnmi�an I:r,ire.
:. .\nt \pplii.iblr ❑ I. Structure rcith in au)�urt apprna dm are•.m' b thou rrvirrc cnmhlctrd,
"i ..r t-n i.t.vnCln Build cnrl, .ed ❑ _ _ le.❑ sir.No❑
+` SECTION 8: CONTENT OF CERTIFICA LE OF OCCUPANCY
LJilnm nl C "ai c: _ C.rl�r��upi.l: __ fm pc.d Cnmin1Cuom llcCupant I im.i per Fnor: _
) u•� the buddumt;amtmn do Sprinkler S\,tem': . ';penal Snpulatiuns:
n
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nated :\ t�.t� C,olft7mtremlrmr IE" E, U �} MALDL—N
XName(I'rint) No.andStreet Cih/Town Zip
Pruperh0%%tier Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the properh'owner herebv authorizes
Name Street Address City/Town Stale Zip
to act on the pro ert% owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) 1.
(It bt,&lin g is less than 35,01111 cu.ft.Ot MClosed s pace and/or not under Construction Control then check here O and skip Section 16.1)
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
Company Name: - . , . . •� r •`.: ..- •.:
y ..
Name of Person Responsible for Construction License Nu: and Type if Applicable
Street Address City/Town State Zip
Telephone No. (business) Telephone No. (cell) e-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 O No O
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 $
4. Mechanical (HVAC) $ Note: Minimum fee=$ _(contact
,rmunicipality)
5. Mechanical (Other) S Enclose check payable to � 09 S�t►t/Ny t
P'Y•
6. Total Cost S (contact municipality)and write the n ber 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.
Ilea,e print .Ind sign name ride Telr Date
�Irrrl :\ddre.. CiK';'To wn Sta e i
i \tuniiipal Inspector to fill out this section upon application approval:
Name Date