CHARTER ST - BPA "AT 26" �. The Commonwealth of Massa.t:huse,tts,
)• C l'r Department of Public Safety -
� ,�••,% \Ia..ddui,eus
State Buildingl"udr l••-80 C\IR) *-%vnih Edit ton
City of Salem I
' '
Building Pe mit'Application for any Building other than a t•ori-Family Dwellin` - �
1 rhos'c tn.n For Official L',e Only)
Building Perrot.Number: Dale Applied: Building lnspectuc
SECTION 1: LOCATION(Please indicate Block s and Lot s for locations for which a street address is not available)
C 1 ( '5<
Vu. and Strrrl Citc i irnvn Lip Gude Name of Building pt ipphcoble)
SECTION 2:PROPOSED WORK
If Nrw Grastnictiun check herr Our check all that apply in the two rows below
Existing Building Rept it❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Ulhrr ❑ Sprafy: ✓Y•Gw Yp (r
Are building plans andlur cunstrumon duaurirnts being supplied as part cif this permit application? Yes ❑ No •R
Is an Independent Structural Engineering Peer Review,r4eyuiErd? a Yrs ❑ No ,(�
Brief Description of Proposed Work: 9 ` it \ Q 7(vt$ V-C .} T G - Yb0 1
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): Y
Existing Hazed Index 780CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Checkas a Ifcable)
A: Assembly A•1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business O E. Educational ❑
F: Facto F•1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 131: Institutional 1-1 ❑ 1.2 ❑ 1.3 C31-4❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
5: Storage 5-I ❑ 5-2 ❑ U: Utility O Special Use❑and please describe below:
5peci:�l
Use
SECTION 6:CONSTRUCTION TYPE!Check as applicable)
IA ❑ IB ❑ IIA Cl IIB ❑ IIIA ❑ [JIB ❑ IV ❑ 1 VA O VB ❑
I SECTION 7:SITE INFORMATION (referto780CNIR 111.0 fordetails on each ifem)
Water Supply: Flood Zone Information: Sewage Disposal: French Permit:
Debris Removal:
m
•I'uhbi 0 l lied il, ul idv ,f,a&-n'Cl hi.hc.rte muinnpal❑ ;\french Will not hr
Il . t.icrmed Un�,J,.il jur,❑' a•
rrtvluired ❑ur trench �-r ,pcat%
I'r n-ale❑ sir unlenlilc Zune,_ , r nn Ir,c,trm❑i I•ermn i.enck"ed ❑ y .
Railroad righl-of-why: Ifaurds to Air Navigation: ll_l I L,L ni, i , .......7..11 R.".,,,
v \, 1 \pldu able❑ I.slru.liiic uhur avl•url apt,„,.illi.vro' I, ihvir i,.%a.r. i.,urhlr6 J'
..i l- •,nrnl b, llui l,IcMln"c-d❑ lc,❑ ,v ❑ lr,❑ \„ ❑
SEC"rioN 8:CONTENT OF CERTIFICA rE OF UCCL'P.1NCY __
I .lilnni, ll "Ic L-v ld�nii`nl fii`v� Il gni-Ini.li"n 0,cup.mt l , .plire 11.mi
-1rm' _ Tri ial�bpul,rlmn. �
�C 164yy4
SECTION 9: PROPERTY OWNER AUTHORIZA PION
{N'y,i me.fi d .\.Id rv,nt Prt rt% 0%w 11 e
cP i aL.Zd
Nan*e tPnnt) No,and Mrvai
Pmperty kh.nvr Contact Infurmeuun:
}�fafa &VV__ &CD_Ifz n£ . � t,�2 s£7f 2 2 lip p'buY Qua pt
rule relephutte No. (bu.utess) rrlephome.M, (cell) r m.ul a.IJ rr�� I
7t epphcat+Ir,the pntperlc o..ner herebv auihonres
Name street Address City/Town Slue Zip
to act on the •ro%,rtv ta.ner s behalf.m all matters rclatn a to n'urk mithorteed by this bu+Wm• •rant{.t t theau.m.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
{tt t=ud.itn•u hro4 thatt}i,tlUlt nt.tt.of.vpaaxd s w'e and/ter rnri utnier CunMrwchun Gxnm!then sherk hers t7.axi�k++�'.tnrt+IU t)
10.1 Re istered Professional Res onsibit for Construction Contra)
{� v- L + W-�- o $2 1,x-6
Name r•intra�tt) Telephone No. a-moll address Registration Number
��� � ��
q 6 w a. �nt rr, s �. D ..J sv O 2 00
Street Address Cityl Lown State Zip Discipline Expiration Date
10.2 General Contractor e� ` �• x^c
Company Name: 4 .
vvx C t CvN% kf <e t C -At-{— . I}..o tJ x't' Co . .L
Pera>n Resp.msthlr t Cunstriictiun License No. and Type if Appticabte
3 7StiiS •C,)CT` SR'+.\(.'t^„h '�t�4 O V 9'l.Q
Street Address City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKEHS'CONMENSATION INSURANCE D VIT(M.G.L.c.152.§ 25C(Q)
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 19 No Q
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs!(Labor
i
and Materials} Total Construction Cost(from item 6)=f 139000,
1. Building f Building Permit Fee=Total Construction Cost x_,._(Insvo here
2. Electrical f appropriate municipal factor)=f
3.Plumbing f r{
d. Mechanical (HVAC) f Note:Minimum fee=f (contact municipality)
5. Mechanical (Othery f
Enclose check payable ro
h.Total Cost f '2„� inmtact muniti !it )and write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Z
niering my name below, I herebv attest under the pains and penalties of perjury that all of the in(nrmeW m r�-nt.unetl❑p fhii
hcatwn �s(rue and accrete fine e bbest ut me know e geand under+landing.
rd%.tom Mote rrlJ Qom`-`A C��-e-If� Drt2i e t?! _ �J�� -f �
I'Ir.nr pnnt.intl .iqn name title telephone A�� Unfc
� _�' C1•t e4s2TC'L-5 i �}'• �
�twvt tddra•,. {•Ifo; r�n.n hf.ite G}`
i
tluniopa) Inspector to tilt out this section upon application approval:
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