149 DERBY ST - BUILDING JACKET f
The Commonwealth of.Massachusetts
Department of Public Safely
�. d••% dnnelse}tale Of,d.bng C,nle(,-80 CA 114)SIv%vn I Ed IIwn
City of Salem
I
Building Permit Application for-any Building Zither than a I• or 2-Family Dwelling
I t This<rcn,rn For Official L'.r Unly)
IAiddmg Prnmt Number: Dale Ap)+lied: Budding Insprchn: I
SECTION I: LOCATION 11"lease indicate Block 0 and Lot a for locations for which a street address is not available)
L q DG-ii¢lad 'z%ll2ECi S(�xl._ELA . MX D 19"1 O
.\o. ind Street Cit, /ro,vn Zi) co'll Name ul Budding tit.Ipp6cable)
SECTION 2:PROPOSED WORK
If New Cun'tructiun check herr O ur check all that apply m the two rows below
Eaising Building Repair❑ Alteration O Addition'b Drmufitiun Cdr IPlaise fill out and submit Aj.+prndix I)
Change of Use ❑ Ch:angdof Ckcripancy- •❑`•.: ... -'Other �Sprci(y: �GlYGF1'�N .'1i; (�VA'J'1bti1•
Are building plans and/ur construction documents being supplied as part of this permit application? Ye+ it No Cl
Is an Independent Structural Engineering Pere Review required? Yes ❑ No Od
Brief Descn ptiun of Prupused Work:
• �9L t1Er�1 CAI,r l il-�5 L& "Melt GAAa 1f3GTS
nI S VQ LA&kitrx 10
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 Cruup(O \ Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: y Proposed Hazard Index 780 CA•IR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) --:�a Q
Total Area(sq.ft.)and Total Height(ft.) 55z 0 las-()C)
SECTION 5:USE GROUP(Ch It as a licable)
A: Assembly A•1 ❑ A-2r ❑ A•2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational (I
F: Facto F-1 ❑ F2❑ H: HI Hazard H-1 ❑ H•2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I.1 ❑ I.2❑ I.3 El 1-4 C) M: Mercantile❑ R: Residential R-1❑ R-2 jU R-3❑ R-4 Cl
S: Storage S-1 ❑ S-2 ❑ U: UtJ_lity❑ Special Use❑and lease describebrluw: •-v
Speaal L'sr:
SECTION 6:CONSTRUCTION TYPE(Check as Applicable)
IA 13 10 13 IIA E3 118 ❑ IIIA a 1118 (3 1 IV Cl 1 VA ❑ VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Su ppl Flood Zone Information: Sewage Disposal:
French Permit: Debris Remuvil:
I ❑ ❑
Pobhc ChciA it�nd•ide P"" A trench will not be Licrmed Dnp,..al Site ❑
Lnnc In.bcite mumcq+al
required ❑ur trench ,.r
I'ricaW 13 „r inJenhic Lone:_ ..r nn ate'% tem ❑
pc•rmu i.enclu.rd ❑ _
I Railroad right-of-way: Hatirds to Air Navigation: \I\ I h.r, n, i ..
\,.t \i't'h-iHy❑ Lslrwlwc„illun.nrpurl.i pi•iudd+.ora' Lthvir n•+iri. o.n+t•I.IcJ'
it n. ItuihlcmL�•rd❑ I le•❑ ,v\i.❑ 1r.❑ ❑
SECriON 8:CO,N TENT OF CFR"TIFICA fE OF OCCUPANCY
I ,Mnm -IlJc L`c l�iuui•ni _ ft i•c�If(- 11,lnhlnnt l irCut•.m1 I 'od rr
I hy.lhp IY II ,I lily,sill 1.1 ill.111 Vt`(111kC(�\'d Clll• _ �i4'CIJ �npu ,nun. ,_ ______.__ -________.
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Yom,,Ow,.Cr-
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SECTION 9: PROPERTY OWNER AUTHORIZA rION
\'ama•.IuJ .\Jdn•s ul l'rul+crit Ucrner '
' SPrRAb1 'DtG(1¢�c�j, 14� QST . SPs>_-�l�h �✓Va- 0�1 .o13_lQ
Name lPnnt) \'o.andStreet lit%; rinen GI+
Pru-1+erh U%,,ivr Contact Inlormauun:
role Telephone No. (Ow.—tit •) retephone No. (cell) e m.nl addrc..-_
If applicable, the prupvrty o,,ner hereby authorizes
Name . truet Address City/Town 561te Zip
e+aat.m the +ro+vrl% urc ner',behalf, n all matters rplauye to murk authorized bv.this bulldn • 'ermn.a +ple.onm.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
I11 t•uddln+IS los than 15,tMx)cu.it.of enclowd s+ace and/or nut under C,nbtnlcbun Conool then check here an.l .kl + to Il
10.1 Re istered Pro/essio�n�a h(--- --- /ib ,`=
lefo�(r Construction Control
W.1
— 4o i • �t 3 1 -7 y1 P
Name(Registrant) TelAphune No. e-mailaddress Registration I mber
14'� 'E7Z�•s'f':. ��gI�1 su5ahv\e w\.m '@ �wlai(
Street Address City/Town Stn to Lip Discipline Expiration Date
10.2 Central Contractor
Company Name:
Name of Person Res nsible for Construction License No. 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 signed Affidavit submitted with this application? Yea❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ tEnclose
Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=5
3. Plumbing S
d. 1+fechanical (HVAC) S
N.
Minimum fee=S (contact municipality)
5. Mechanical (Other) S
heck payable to
h. Total Cost S ,Qunici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
H\ entering my nairy below, I hereby attest under the pains and penalhrs ul pequry that.dl of the m/urmahun c,�nlalned in this
.application Is true and accurate to the best ul my knuwladge and undervlanding. -
I'Iv.,w print.Ind•ign lmry rrtlr
11icvl \+LIn•" ( Iter
\IUnIClpJ1 IIISpe(tnr t0 till out fh14 sectio n Opnn JppIICJ tion Jpproval:
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39 'n' 24
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18" 6" 0 24" 18"
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1/2"=1'-0'; 149 Derby St 7/10/1