25-30-40 COLONIAL RD - BUILDING PERMIT APP Lots 06 11 0! i/ o>�i
,• ;i The Commonwealth of Massachusetts ��
?'. I Department of Public Safety ^ �'3
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\Lr<s.uhu.cltNStateBuddingCnde(7800\1R)SeventhEditiun 4iii0l �r 5,,-
City of Salem
Buil11
din Permit 0. lication for an Building other than a I-or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Dale Applied: Building Inspector:
SECTION 1:LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available)
X
2S-/30jY0 Coin r&e/%( &t� Cy�t i3�, > ai F-
No.and Street C ih' /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 rows below
Existing Buildin A
Repair❑ Alteration ❑ 1 Addition❑ Demolition Please fill out and submit Appendix 1)
Change of Use ❑ 1 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!
_ ,0L 1��n2pLt7r,-rl D� FSC f sT b
i
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): t
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 4:USE GROUP(Check as applicable)
A: Assembly A.1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A 4❑ A-5❑ B: Business ❑ 1- Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1 ❑ 1-2 0 I-3-❑ I.4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-40
S: Storage S•1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTIO_ N 6:CONSTRUCTION TYPE(Check as a plieable)
IA 16 13 -_- IIACl11110 IIIA ❑ 1118 ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Su I Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y�
Public❑ Check if outside FlaMnf Zone❑ Indicate municipal❑ •A trench will not be Licensed Disposal Site❑
1'rit ote❑ air mdvaink Zone: or on sije s('+arm❑ required ❑or trench ur,recdr;
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: �tA.l li.o'nc C�nnmi..inn I&a ire I'n r��:
..Nod Apt'lic'11,1V❑ Is Structure tcohm airport apt+reach area? Is their res le%% omaplewd'
r t rnncnt In Hudd enclo+cd❑ Yes❑ or No❑ ❑
SECTION 8:CONTENT OF CERTIFICA"FE OF OCCUPANCY
Edition of (l,de; _ L'.e(:n nitihl: _ Ttpe of Construction: Occupant Lund per llnor .
IL�e+the btnlding conwin an Sprinkler Si,lem": Special Stipulations! ._
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.tildAddressolPn�pertvOwner /' /�
UNI✓1}IZc f./'SAa � �7 V .C.>y�sr+l a�f"e( � r_ /`�t 4Y 0( 0
Name(Print) Nu.and Street City/fawn l Zip
Pniperty Owner Contact Infurmatiom h y�rr� �y�r rrc g
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Title Telephone No. (business) Telephone No. (cell) a-mad address
If.1 the pr°perry owner hereliv authorizes
VIC",
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this buildin> permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
{It building is lea's than 35,(Mcu.ft.ofendo"s ace and/or not soler Gm+truction Control then check hen 0 and.,kip Section RIA):.
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town ;tate Zip Discipline Expiration Date
10.2 General Contractor
cem/wlla, 9sJ`�Irrw „tom
Name of Person espu Bible for Construction ,w f r an icense No. and Type if Applicable
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Street Addr ss City/Town Zip
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Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORI(ERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.A 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? 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_(Inserthere
2. Electrical $ appropriate municipal factor)_$
3.Plumbtn $
S. Mechanical (HVAC) S Note:Minimum fee-$- (contact municipality)
5. Mechanical (Other) $ Encktge check payable to
X b.Total Cost $ ��ia coo (contact municipality)and write check number 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 a bes
o my k w edge and understanding. l", q O I 9 /
Heaac print and sign name Title Telephone No. 0,11t,7 /n iv CGirvro�+� d�s�a
I( ?trtct Address Cit.%Town State Zip
Municipal Inspector to fill out this section upon application approval: 4 AO— -
✓ Darr
r
G Cons tet.
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION DATE
ASSESSORS � DATE a-t 11-4
93 Washington St.
CITY CLERK DATE
93 Washington
PUBLIC SERVICES DATE
120 Wash' ton St.
WATER DATE L 60 'o6moCv fap
120
Wash
in ton St.
.a -1
CR�ONION DATE
i l�rh 2
— 2f 'Si Ave
PLANNING --� DATE lie
�i 0
120 Washingto St.
CONSERVATION 5eC AIM4DATE 2a/0
120 Washington St. -
f ELECTRICAL DATE /% A2
Z 48 Lafayette St.
FIRE PREVENTIO
29 Fort Avenu F
V�
HEALTH I DATE
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.