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;s. The Commonwealth of Massachusetts
Department of Public Safety
\1ass.uhuselts Slate Building Code(780 CIMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section F))r Pfficial Use Onlv)
f 1 / Building Permit Number: Date Applied: id ? Building Inspector:
SECTION 1: LOCATION (Please indicate Block#and Lot# for locations for which a street address is not available)
`]7 MDL-r 5-r- S46�M N\4 D 1 `17 l7
No. and Street City /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 Building Repair Alteration ❑ 1 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
Is an Independent Structural Engineering Pe r Review required? Yes ❑ Nd' /�
Brief Descripti m of roposed Work: /a-�—
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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): a•
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.) 7
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-1 ❑ F2❑ 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 IVO VA ❑4Removaht...
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Suppjy: Flood Zone Information: Sewage Disposal: 1
Trench Permit: Dal:Public Check it outside Flood Zone❑ Indicate municipal d A trench will not be Licentiite arequired ❑or trench o�r sypePrimate ❑ or indenlifa Zune: or on site system ❑ permit is enclosed ❑ rIKRailroad right-of-waHazards to Air Navigation: \L\ I liauri, C�nnmi'>i�* c..;� Is'StrnCtllrCmcithinairpnrtap roacharea? IS their re% em cor llmsenttii'Build enclosed ❑ Yes Q or No 1'rs❑ \SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
TcpeofConstruction: Occupant Lund per Flo
Dues the building contain an Sprinkler Svslem?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION s
:N. e. Li Add f Property Owner
,4E �PnC coy R(��b�, l� S r Fars(u'�rJ M°r �r9
Name(Print) No.and Street City/Town / Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to acton the v'o pert%owner's behalf, mail matters relative to work authorized by this building permit a plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and ski i Section 1t).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
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Name o Pe son Responsible for Construction 1111 License No. and Type if Applicable
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Street Address City/Town State Zip
c 1 !23 9 /4 - S_f �. z i �w c �- e Gong me r f k1.,
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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor ,S7�
and Materials) Total Construction Cost(from Item 6. _$ V U
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ nya
4. Mechanical (HVAC) $ Note: Minimum fee=$ ct murtECipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ a<�M (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
application is true and 1CCLiratq,,tq the best of my knowledge and understanding.
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Please print anc1 ihn nam Title Telephone.No. Dote
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Street
ZStreet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: • SI
Name
'*L*NS1Mb6T9EfR&9-AND APPROVED BY 774E
JMSPECI OB PWR TD A PERMIT BMG GRANTED
CITY OF_SALEM
Now � Data
Wald !r
/ Zoning Dlstrlat
I Ma HWoric DMft?� Yee No UL"r of
>snildin6 2z 2141-44—
Is AWaty Loetlsd In
fiw Cansarvaaon Arms? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
epeir/Repla Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accord,ig.to the following
specifications:
Owner's Name r FO-Z&re '1'k ti
Address & Phone 6 Z fSi zw ��� S ks+n �tA (off - � C :/I PS—
Architect's Name
Address & Phone
Mechanics Name
Address & Phone
What Is the purpose of bWWW �i i-n; 4-
Mat w of bWldittg? \✓y- , vt,a If a dwsev.for tow many tamem? <`
wo drM kV contom,to law? y 0,5 Asbestos? :nio
Estirnatad cost 'x<b U cly uranes• 101uq she Lk ims r
Lic. t Sipnatu—re o Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE 9
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MAIL PERMIT TO:
APPLICATION FOR
PERMT TO
LOCATION
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PERMIT GRANTED
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INSPECTOR OF BUILDINGS
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-Pt*M-MOST-OE f4lz-E ID APPROVED BY T*IE
.jWfCTDR PWfl TD.A PEMT BEING GRANTED
CITY OF SALEM
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No. _ V� •` .L Date I
1 Is Property Located in Location o7 \ 1
J the Historic District? Yes_No_ Building
Is Property Located in
the conservation Area? Yes_No
tsi�yn BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) of, Install Siding, Construct Deck, Shed, Pool,
Repair/Replac , Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name C7az&,r ANC N
Address & Phone &Z !Nut 6 T �w^" �r+g - 6ac-I lvr
Architect's Name
Address & Phone
Mechanics Name
Address & Phone 1
What Is the purpose of building? dux I rn
Material of building? WDoD If a dwelling, for how many families?
Will building conform to law? V Asbestos? n o
Estimated cost /D�DOD City License a N A State uc nse M "1'I l7
Home Improvement
Lic. I
Signature of Apofcant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: 1y2 g Int b��h 9AM I - CW PA Oigt;Z-.
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.IMSPF 110 PRIOR TD A_PERMIT BMG GRANTED
Na���— �\ CITY OF SALEM
Data /S oy
Ward 2
�- Zordng District
Is Pmperty Located In Location of
the Historic Dlsidct7 Yes No &dlding 72-I3LL1)6E
s Property LoceW in
Itha ConservatIon Area? Yes No
Perm it to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof Install Siding, Construct Deck, Shed, Pool,
Repair/Replace Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accordNig.to the following
specifications:
Owner's Name t-Tenn r-5- 72 tSYJD St M.
Address & Phone Ca, '$iNLL % /,I �_/,gym, 6881
Architect's Name
Address & Phone ( t
Mechanics Name
Address & Phone
Whet Is the purpose of buikUM?
MabrW of IX A ft?_ 1r%. T u�j II a dweNing,for how may famon?4_
WO bukkng cardonn to law? !d -Asbestos?
Esflmated cost f'/_h-6o Gry ucerw o / I _State ucertsa N
Boar Improveaent G —
Lie. 1
Signature of Abblicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION
'O�IF.WORK TO BE DONE C
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MAIL PERMIT TO:
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No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
19
APPROVr�
INSPECTOR OF BUILDINGS
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