60 WASHINGTON STREET - BPA - DUNKIN DONUTS 6
f ^J
li The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code 1780 CMR)Seventh Edition
City of Salem
Building Permit ApElication for any Building other than a 1- or 2-Family Dwe lin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Z' Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street addtt avai a le)
?k �T , fr7� ( ott
No.and Str t City !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 Building❑ Repair❑ AlterationAddition ❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Change of Occupancy ❑ Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Pger Rev required? �, f� Yes O No
Brief Descrip - n of Proposed Work: PGI O M / "Z
C
dAI AJ
ac t4'
i
SECTION 3:COMPLETE THIS SECTION[F 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); t'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTIOW-47 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 S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ .A-2r ❑ P;2nc O A-3 ❑ A-4❑ A'-5 13B: Business-❑ ' E: Educational ❑
Fa
F: cto F-1 ❑ F20 I H: High Hazard -H i`O H-2❑ H-3 ❑ H4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ (-3❑ 'J1 4 O M: Mercantile O R: Residential -R-10 --R-2❑ R-3❑ R-4 O
S: Storage S-1 O S-2,1D ' U: Utility❑ Special Use O and please describe below:
Special Use: `
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 13 IB 13 IIA ❑ IIB 11IIIA 13IIIB [3 IV IV ❑ VA VB O
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: { Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check it outside Flood Zone ❑ Indicate municipal CJrel aired❑or trench or s
l vCj fv
Prlva to❑ or indentifv Zone: or on site system ❑ 1 hermit is unclosed ❑
Railroad right-of-way: Hazards to Air Navigation: 1L\ I!rotor Coinnp, i� n �:rr io,, Pro.....:
Not Applicable❑ Is Structurc:i ithin airp, rt approach areal l+their revieiy c'umpleted'.
or C'0m1ent to Build enclosed Cl Yes❑ or:No❑ Yes ❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
)idition of Coda Ue Goup(s): _ Tc pe of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations: -
j2�1G
SECTION 9: PROPERTY OWNER AUTHORIZATION
Na e and A ess o Pruperh Owner
Name(Print) Nu.and Street City/Town Zip
Pr lcrty Owner Cr pct Intor ition: /"K _-
Affe�At 0j" W Ay
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the properhv owner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the pro perh )Ne ner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION-10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
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 Na42 73 I�Z31417
e:
Name u�f�IP'ersuJ� Re��sp�nMibjeA„r Construction License No. and Type if Applicable
f l' LQJ�LL C/E
Street ress � l� City/Towry�,,,r-r� $tm 60 zip�C
Tele hone No.(business) Telephone No. (cell) ( e-mail address /
SECTION 11:WORKERS'CONTENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ ` r— Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $
Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 6 (contact municipality)and write check lumber here
SECTION 3: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 s true and accurate to the best of my knowledge and understanding.
�7-AW---
Please ®r]pt, d sign name r Tit] Telephone 'o Date
Street Address Cit%/Town Stat I
Municipal Inspector to fill out this section upon application approval •. tt
Nam lu J.ite