75 WASHINGTON ST SUITE 205 - BUILDING INSPECTION •,�:,. The Commonwealth of Massachusetts
Department of Public Safety
`w -f %lassachusett,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# and Lot# for locations for which a street address is not available)
No. and Street Ci1v- Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Buildingm, Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 19'
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Bri-f D^scriptirof Propo: d Work:
n
r
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 5: USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business E: Educational ❑
F: Facto F-f ❑ 520 - H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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 ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Ls Removal:
Public❑ Check if outside Floud Zone❑ Indicate municipal ❑ A trench will not be Disposal Site❑
required ❑ or trench
Pri ca to❑ or indentifv Zone: or onsite system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I liaorie C�nnmi..i�m Rev i,,, Prier..:
\ul apphcA le❑ Is Structure mcilhin airport approach area' Is their reciemv completed?
or C nnNent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
lidition nl Code: Lse Gnmp(s): Tvpeof Construction: Occupant Lund per Floor
Does the building;contain an Sprinkler Srstem?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street Citv/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit a p plirition.
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❑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
7 r
CMM 4 ���1-e-r c S x, ;- �
XXkk 9
Name of Person Ressorsible,for Construction License No. and Type iicable
� & ja ll i3� f pplold f5
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? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$ 200
1. Building $ two Building Permit Fee=Total Construction Cost x.3�(Insert here
2. Electrical $ appropriate municipal factor)=.$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contactmunicipality)
5. Mechanical (Other) $ Enclose check payable to 3,3-
6.Total Cost $ 31 0 V U (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
applicatio is tru and accurate to the best of my knowledge and understanding.
d�_� �/ h�t46/oo
2ti o ou 6 -21 _09
Pleas nota l .i mi Titleone No. Date
�.. 3 >u Q Q o C4 f
eet Address Cit%/TownZip
Municipal Inspector to fill out this section upon application approval: