0017 PARADISE RD - BPA-15-1293 STAPLES iZ ZLt `7
The Commonwealth a Commonwea t of MassachuR#W
Department of Publicd&jj? CT10N' :E SER`dICES
(`n Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other thagffft offmjg!fe!!�Dweljing
C Ttils Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
17 Ags2/S 13642 56245 i A,4. 02,162 s%� S- R&IL si BPS
1 No.and Street City/Town Zip Code Name of Building(if applicable)
f1 SECTION 2 PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing B� Repair❑ Alteration K Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes K No ❑
Is an Independent Structural Engineenn_ Peer Review reqquued? Yes 13 No
Brief Description of Proposed Work: S6L 0 S /d/ " T'-
4f441- e5!6Lt L/
CAW W,
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): AEFRCAW77C6 Proposed Use Group(s):
JN—
SECTION 4:BUILDING HEIGHT AND AREA
Existin Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 13t L 2Wrl14/qL9
Total Area(sq.ft.)and Total Height(ft.) *.5,4,4b pr 0j85o -:'�Z1r
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2 131-3 0 I-4 13M. Mercantile)9 R Residential R-113 R-2❑ R-313 R 4❑
S: Storage S-1 13' S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ ITB ❑ IIIA ❑ IIIB ❑ 1 IV AL I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone on: Sewage Disposal: A trench will not be Licensed Disposal Site K
Public 91 Check if outsidea Flood Flood Zone❑ indicate municipal R(
Private❑ or indentify Zone: or on site system❑ required X or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable P, Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed E3 Yes❑ or No A Yes❑ No Jef
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: A*lk_Use Group(s): AA Type of Construction: �= Occupant Load per Floor:
Does the building contain an Sprinkler System?:-YTS—Special Stipulations: 3/✓i�tITS
3 -4511 u— 51=7"S oP �s �76�,TTE!l>.
P
-f1ktEa� -co V. U. - 1Z1 t
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
KlA*co gaa-Y ag? Rp• u3c4 &a PARK / ry, Y. //0 a
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
M& aggsj 6P)Z-29- M.5V !a1-W- WD A✓ l�K toR ce
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
RAL* x. 46r to
Name a strant)) Telephone No. e-mail address Registration Number
Zai I&V DR7tkf wBYitfalt7f y�_O2189 A&&2&r 1:2 l6
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
mp y ame
04q 63 a
Name of Perff Responsible for Constructio license No. and Type if Applicable
3
z
rS get Address V '-City/Town S Zi
M4& 6t /
U - • CCJ
'
Telephone No.(business) Telephone No. celle-mail address of
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O No O
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_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclosecheck payable to
(�
6.Total Cost $ 3-6,0/ ; (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
a tion is true an e to the best of my knowledge and understanding.
Pl se d t Title Telephone No. Date
Street Address City/Town tate Zip
Municipal Inspector to fill out this section upon application approval: ' `Nnr^n w-✓ fll a
Name Date
I
tt, Initial Construction Control Document
To be submitted with the building permit application by a
` 4J Registered Design Professional
for work per the 81h edition of the
itf a
Massachusetts State Building Code, 780 CMR, Section 107
['reject Title: 5,7V,t7o Aa;j L- Date: / /i _
Property Address: )7FA#W1W fjdo§j7
Project: Check one or both as applicable: New construction X Existing Construction
Project description: � yt1B 3L CA7AnfS f1.519�_$ CBS C{� byju Y T
IIPfW � I LrAb1L �trWWSrie�S R3 WInIKI< 14d totoQ'CajirTd; P1Wtfj2
I X1.1'//' /4.C6'r11t& MA Registration Number: +?J• " Expiration date:��3���1P ,am a
registered design professional, and 1 have prepared or directly supervised the preparation of all desig plans,
s,
computations and specifications concerning:
[y� Architectural [ ] Structural [ ) Mechanical
[ ] Fire Protection [ ] Electrical [ ] Other
fbr the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR.),and accepted
en_ineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
I. Review, for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to detennine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit t AR inal Construction Control Document'.
Enter in the space to the right a"wet"or Q
electronic signature and seal: o: No. C
3 t'EMBROKEn
'o MASS. u's
Phone number: 7 I' �� 9t� of
p Email:Reg�LACYJ�JNSi '�31'1rl97 ,i'T 'N�
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Surve /hlvestiation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other S
21 Other(Specify)
22 Other S
*Areas of Design or Construction for which plan are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
ill K i� -?81-331- 5�cA�'uA �1Nst /� , S ,NtPr +39
Name(Registrant) Telephone No. e-mail address Registration Number
ay ,trSeN Az)r'd` Itlt3Y�t i A • o r e i r6
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci Town State Zi Discipline Expiration Date
. Initial Construction Control Document
UTTo be submitted with the building permit application by a
Registered Design Professional
for work per the 8'h edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: STAPLES Date:10.21.2015
Property Address: 17 PARADISE ROAD SALEM, MA
Project: Check one or both as applicable: ( )New construction ( x )Existing Construction
Project description:
1,Raymond W. Dusseault Ill, MA Registration Number: 40709 Expiration date: 06130/2016 , am a registered design
professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning':
Entire Project Architectural Structural Mechanical
Fire Protection Electrical X Other:
for the above named project and that such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee) shall perform the necessary professional services and be present on the
construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and t
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, 1 shall submit to the building official a `Final Construction Control Document'.
`�ra` M OFy•q
Enter in the space to the right a"wet"or �� y. ••• •• 9 '.�
electronic signature and seal: r ORUAMOUDyyi
* ELECTRICAL
• DNo.<07Qg
r't3TEQ��•r�Q
Phone number: 401.765.7659 Em/r r sseaultt@edesignservrce.co `�••• ••
Building Official Use Only
Building Official Name: Permit No.: Dale:
Note I. Indicate with an`x; project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen,
pmvide a description.
Trial Version 10 09 2012