11 FOSTER ST - BPA-2009-818 DOORS The Commonwealth of Massachusetts
Department of Public Safety
\ ._••i \la.ssachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a s re t address is not available)
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No.anY Street City /Town Zip Code Name of Building (it applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair VtAlteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appen11)
Change of Use ❑ Change of Occupancy ❑ Other ❑.Specifv:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Revrw require ? No ❑
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Brief Desion of Pru )seed Work:- '
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): r
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: Assembl A-1 ❑Y A-
2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
L• Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-l❑ R-2 ❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B ❑ IIIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
PP Yi :
Water Supply; Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ Check if outside Flood Zone ❑ Indicate municipal ❑ '\ trench will not be Licen,e•d Dinpos.il Site❑
Zone
❑
I' required ❑or trench nr.periO':
ri)d 0.• ire utd coots :_ or on <i to.c.tem ❑ -
permit ie enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ li�lri;t inmi n I:. ....r
p1111111,111
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\� t \F hcilJe ❑ - I I:titruRurc ,cithin.rn'F•r rt ,tpF,rn.tch ,tee,).' In lhcurc)ic)c rnm(,Icicd'
i 'l menl hl Itui lei enc 11"I'd Cl _ .1'c.❑ ..r \o❑ 1'r.❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Cdili� n ��t C Laic. L',l,rou),i.l: _ i)pc of Con,truruun: t)ccupdnt I Odd per Ill,m:
[).'I" thc•budding unttdinan Sprinkler Sc-.cm': _ Special Stipulations
"l ��Z/� ZI w( �
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nau j,I nxid,ir•.�..ul Pro pUrtv Owner„
�J�� CitIN'/ own r Lip
Name(Print) No. and tilrc•et T -
Property lhvner(' nt.iet Information:
Ile Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the propem owner hereby authorizes
Name Street Address City/Town Slate Zip
to act on the pro pertowner's behalf, mail matters relative to work authorized by this buildin 6 permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buddin•is loss than 35,1)(1)cu.ft.of vndused s*ace and/or not under Cunstnidiun Control then check here O and skip SldiUn 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
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10.2 G rat Contractor
Cu pt ny I�etmeL Dl� /� �^ � y7 Y
Name of Perso Respt Bible for unstruction License No. and Type if Applicable
St Address �d3�3 ity/Town Staatm
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? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item 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 $
$ Note:Minimum fee=$ (contact municipality)
4. Mechanical (HVAC)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ aa. p77 (contact municipality)and write check number here
SECTION 13 SIGNATURE OF BUILDING PERMIT APPLICANT
By entenng 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 a curate to the best of m% knowledge and understanding.
777 J--
I I�� f tint an ago : m • title Telephone \n. Date
�I rt•rl :\d.i re.. Citvi Town ((ate Zip
Municipal Inspector to till out this section upon application approval:
\'ame I)ate