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B-17-1126 - 0015 BROADWAY - Building Permit L!V The Commonwealth Of WS64aw'se#tS Department of Public Safety Massachusetts State Bur d��80 I� Building,Permit Application for any Building olherr than a One-or-'Fwo-Family Dwelling (This Section For Official Use Only) ^ ll Building Permit Number: Date Applied: Building Official: \v SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # 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 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 x Is an Independent Structural Engineering Peer Review required? Yes ❑ No JK- Brief Description of Proposed Work: 044 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 ❑ 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❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: 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 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 municipa A trench will not be Licensed Disposal Sit Private❑ or indentify Zone: or on site system❑ re mit e trench or specify: per requ mit is enccll osed❑ Railroad.right-of-way: Hazards to Air Navigation: MA Historic Conunission Review Process: Not Applicable, Is Structure within airport ap roach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No Yes No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition 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: SECTION 9: PROPERTY OWNER AUTHORIZATION i Name and Address of Property Owner 464f t P�- 22,450 S17 1WSP �� (I T Name(Print) No.and Street City/Town Zi Property Owner Contact Information: ,PNLO 70.E 9 269-0 raj 2s�4s-2-0 tc644_W kg CO Title Telephone No.(business) Telephone No. (cell) e- dress If applicable,the property owner hereby authorizes: Name Street Address 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 M,000 cu.ft.of enclosed space and/or not under Construction Control then check here 131. . Otherwise provide.construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals). Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name o Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town ff-- State Zip �� p -t.r'11u f � �ZO" •n"`'G Telephone No. business Tele hone No. cell mail ad res 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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ l 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 $ Enclose check payable to 6.Total Cost $ (� (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name b low,I hereby attest under the pains and penalties of perjury that all of the information contained in this a lication is e an ccurate to the best of my knowledge and understanding. Please pr' a sign name _ Title V Telephone No. Date �� gam " t Street Address City/Town State Zi Email Address Municipal Inspector to fill out this section upon application approval: yn � Name Date -;Z.s�f ,0z0 3 CITY of S�U.E1N1, INLkSSACHUSETrS $1:II.DIi�G DE1'.�RTrIE►`vT S 120 WASHINGTON STREET,YD ftooR TEL (978) 745-9595 it FAX(978) 740-9845 KjxIBEALFY DIUSCOIL k;z� ► ®R THO"ST.PWRE DIRECTOR©F PUBLIC PROPERTY/BUn DLNG COMMISSIONER Demolition Permit Sign-Off (Supplement to permit application) hereby supply the followin releases as part of the application for a permit to demolish the structure located at 0 f4 k-&5..,. ._ .r_ ..._ ^ and shown can the Assessor's Maps of_ as biting on Map # Block# Lot# Q07r- The 8`h Edition of the Massachusetts 'State Building Code, 780 CMR, ;Mates in part: "A permit to demolish or remove a building or stnicture shall not be issued until a release is obtained from the utilities, stating that their respective service connectioszs and appurtenant equipment, such as meters and regulators,have been removed or sealed and plugged in a safe manner." Utfity to be.Notified ; Notice Received b Date Received Gas t/ Telc one. Electric t/ �Iu:bjl:ie_Vtil i ties Munici ai I..I-Iealth Tie ap rtrnent_ i ! Fire Department Other � Other- Demolition debris hauler: Location of licensed derriolition debris landfill: Signature of Applicant j 1 I`7 Date: i Signature of Owner �I�lk� _ Date: tI a This sheet must be returned to the Inspections Department along with a completed application for a permit, a site plan, and any other applicable information and fees,- - ]74mc�pernt.dcx: City of 'Sttlpmc tt55ttr use is 31re igrpartmrat AreDq unrters PRE-DR'DLITION APPLICATION FDR PIIT I.tt acoo MLq end Salem Fite p th t provisions of the Salem Fire (fie and Salion is 'Cn HB9ulation #29C Wade under , and Salem Fire code, issued subjectrequested of the proposed structure the authority thereof; an Coe, uederpx0� s o to the following f�9�rules or to 'be r�eca mEndat�s which shall be a °erie t ��lied Owner of Land Addres9 of Pm jest j Is "'LsPec*iensred bye � vLA Address of Applicant 1. Per the manner under Provisions Fire Code this structure shall be demolished ' the Salem Building sInsp of the Mass u► a worlaranlike pector•for saidSdenvl t g e �d E! t issued by 2. All debris fzxm each days activities and wet down at the end of each workda shall- be kept apart from the t hours . the site Y� No debris shall accumulate basic structure at any time. site, and no arr�r+e than twenty (20) c�m�ulate over twenty-four Percent of any one day's debris, 3- The use of City of Salem Department or by use of a Paid water be approved b 'the City of Salem dater De Y •• Y firefighter on watch. of said ueldingcontractor and cutting have aentg �-Pment c welding and cutting perndt in effect. Use Bureau regulations. cutting shall },�e authorit A paid off-d subject to the Salem Fire Prevention Jurisdiction s where fire watch may be r increased fire hazard. cases where it is deemed necess required by the �Y. because of forl Failure to perform t� operations in an a 1 immediate around the clock" pprovrlair�nlike manner, may This shall be taken into consideration b watch by a Pad fire de Y be cause ` of this Partlrent detail. i Y a- • Contractors and shall serve as notice for this f Wit. '� advance Pa anent .,,,,,Contractors recrurt�ci :�!�+e;. ':eRed n ecess 11Cant's signature Flonn #29C (Rev. 9/77) All work will be performed in accordance with Massachusetts General Law,527 C MR Massachusetts Comprehensive Fire Safety Code, 780 CMR Massachusetts State Building OC Salem Ordinance and the above stated conditions. ode, City of SALEM FIRE DEPARTMENT FIRE PREVENTION DIVISION 29 FORT AVENUE I SALEM,MA 01970