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B-17-764 - 0013 APPLETON STREET - Building Permit . , cz,1:::� 1 05 The Commonwealth of Massa Department of Public Safety ' r �xf „ Massachusetts State Building Co 780 CMR) Building Permit Application for any Building other t hlalfte{ g TA01Pq34y Dwelling (This Section For Official Use Qrly) Building Permit Number: Date Apphed Birldirig OfficraL`a r �.. SECTION 1:LOCATION No.arid Street City/Town Zip Code Name of Building(if applicable) SAssessors Map# Block#and/or Lot # SECTION 2 PROPOSED WORK -.. N'®J Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑- Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) 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 Peer ijeview required? Yes ❑ No ❑ Brief Des .ption of Proposed Work: f 1 W a-u-S O 7 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): Proposed Use Group(s): 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-2❑ Nightclub ❑ , 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 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ T Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: .Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Editions of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: U,,r (V vj t�5 E + <• SECTION 9"PROPERTY OWNER AUTHORIZATION Name and Address of(Property Owner 9 � Name(Print) No.and Street City/Town Zip Property Owner Contact Information: M Of 3 Title Telephone No.(business) Telephone No. (cell) e-mail address Iffapplicable,the propertyowner hereby authorizes: o Name Street Ad ress City/Town State Zip to apply for and 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 1) If a building is less than 35,000 cti.ft of enclosed space and/or not underCoristruction Control then check here❑ Otherwise rovide.construction control.forms see section 107_-in ttie code as r. uued. •"ti 10.1 Re 'stered Professional Res onsible for Construction Control(the,professional coordinating document submittals), Name(Registrant) Telephone No. e-mail address Registration Number 0 ,� X12S2� c �. 2. 49 Street Address J City/Town State Zip Discipline Ex irati n Date 10.2 General Contractor� [ C. I Company Name © 7 0 -2- 07 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip tv:�14 T, 90 T_cM.)<2_ �. w y-CA—7. c G_w 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 3 Q / and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 436 , Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical WAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 7 �f d _ Z (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I he eby attest under the pains and penalties of perjury that all of the information contained in this applic 'on i true and accurate o the best of my knowledge d understanding. �2-6 r4 r Please print and sign name Title Telephone No. Date �-1Z�" � T,06 s oy-� Street Address City/Town State Zi Email Address Ij Municipal Inspector to fill out this section upon application approval: Name Date DocuSign Envelope ID: 1917C1C0-B606-4595-8237-B9C579ACDEFA Permit Authorization mass save Form PART]CIPATING e Q CONTRACTOR Site ID: S00050277575 Customer: CATHERINE WALSH I, CATHERINE WALSH ,owner of the property located at: (Owner's Name,printed) 13 Appleton St#1 SALEM (Property Street Address) (City) herebyauthorize the Mass Save Home Energy Services Program assigned Participating Contractor listed gY g g p g below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. D�olcuSig_ned by: Owner's Signature: ram- Date: 4/8/2017 1 12:22 EDT aa000aooa00000000000000aooaoa0000aoaoa0000000a0000aoaaoaaaa00000a000 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Da e 0:#0 CLEAResult • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472 0),: For Office-Use Only Rev. 102015