B-20-514 - 0023 BEACH AVENUE - Building Permit i
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The Commonwealth of Massachusetts
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Department of Public Safety
Massachusetts State Building Code(780 CMR)
1 Building Permit Application for any Building other than a One-or Two-Family Dwelling
'O This Section-For Official Use Only) - -
Building.PermitNumber: Date Applied: $uildmg Official
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SECTION 1:LOCATION(Please.indicate Block#and Lot#for locations for which astreet address rs,not.available)
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No.and Street City/Town Zip Code Name of Buildu1g(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check alt that apply in the two rows below
Existing Building)) Repair I Alteration)1 1 Addition❑ 1 Demolition A (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 Peer Review required? Yes ❑ No ❑
Brief Description of.Proposed.Work:
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SECTION 3 COMPLETE THIS SECTION IF.EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
- •-- - - CHANGE IN USE OR OCCUPANCX
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.)
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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❑ B: Business ❑ E: Educational ❑
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F: Facto F-1 ❑ F2❑ H: High Hazard H.-1 ❑ H-2❑ H-3 ❑ H-4 0__, H-5❑
1: Institutional 1-1.❑ _I-2:0 I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ ,,R-3 ' R-4❑
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torage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
ial Use:
SECTION 6:CONSTRUCTION.TYPE(Check:as applicable),-
❑ IB ❑ - - -IIA ❑ IIB ❑ IIIA ❑ 11113 ❑ IV ❑ VA ❑ VB 0
SECTION 7.SITE INFORMATION(refer to_780_CMR 111.0 for:details.on each item) ¢4p`a a = c r`"�-'
R i brs emoval:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: De 0 +:
Public Check if outside Flood Zone❑ Ind.icate municipal`s
A trench.will not be Licensed Disposal Site❑
required, or trench or specify:
Private❑ or i� dentif Zone: or on site system❑
permit is enclosed❑ ®Ian—gal '
Railroad right-of-way: Hazards to Air Navigation: MA Historic Cornniission Review Process-
Not Applicable ._ Is Structure within airport approach area? Is their review completed?
or Conseiit to Build.enclosed❑ Yes❑ or No Yes❑ N.-9
SECTION 8:CONTENT OF CERTIFICATE_OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: 000 Occupintl,oad per Floor:' .
Does the building contain an Sprinkler System?: AO Special Stipulations:
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SE%__iON 9: PROPERTY.OWNER-AUTHORIZATI-.
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N me and Address of Property Owner �y
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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 ad less
If applicable,thro erty owner hereby authorizes
Name Stre t 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.
SECTI.ON MO CONSTRUCTION CONTROL(Please fill:out.Appendix 2),i.
If buildin is less than 35,000 cu.ft.of enclosed s ace and/or:not urider_Constiiiction Control then beck:here❑.and ski Section 10.1
10.1;Re istered Profes..s onai Ites onsible for Construction Control
47 - 3 7 Cam° .qxM
Name(Registrant) Telephone No. e-mail address Registration Plumber
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Npme.,
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address % City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
SECTION.11-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL c.152:§25Ci6)
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must oe completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building pen-nit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONST;RUCTION COSTS AND PERMIT PEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$1 , 0 0 0 ._
1.Building $ -� 000 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ (,810 4 � 000 appropriate municipal factor)=$
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3.Plumbing $& ri~3119 0 0 j
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 000 (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 accurate to the best of my knowledge and understanding.
Please pri and si n narae ....� 4r�--. ; Title Telephone No. 4�at i
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Street Address City/Town tate ip
Municipal:Inspector to fill out this section upon application approval:
Name Date
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Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate.Block# and Lot #for locations for which a street address is not
available)
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No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No O 1
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
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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.
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Checklist for Construction Documents'
Mark"x"where applicabIe
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 Existin Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans 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-Do triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Registration Number
Name(Registrant) Telephone No. e-mail address I
Street Address City/Town State 1p
Discip:ine Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discip_ine Expiration Date
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Commonwealth of Massachusetts
M Division of Professional Licensure'
Board of Building Regulations and Standards
Constrvt �ltdpervisor
CS-098313 t4 fires 05/04/2021
DANA J ROSS JR
2 BAY VIEW AVEIU° e
SALEM MA 01970 +
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Commissioner
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