B-17-716 - 0028 UPHAM STREET - Building Permit W
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1' (This Section For Official:Use Only)
I Building Permit Number: Date Applied: Budd ng.Officiil:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK.CQ o
Edition of MA State Code used If New Construction check here Cl or check all that apply in the two rots belor
Existing Building kReair Alteration ❑ Addition❑ Demolition ❑ (Please fill out quid submit App@a-clix 1)
Change of Use ❑ nge of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
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Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Pro,posed Work: R CMO rJ� ✓�Gf " ��e f �-e c-K LL&Q0 2 :W.
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❑ I 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❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
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 ❑ IIIAO IIIB ❑ IVO VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Su.ppl Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public 19 Check if outside Flood Zone IVI Indicate municipal
A trench w'l not be Licensed Disposal Site Er
required or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-wa} Hazards to Air Navigation: M,�\_l listori�:-Commission.Ijc��ic-ty Proc,!ss:
Not Applicable Gd Is Structure within airport appr ach 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: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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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 address
If applicable, the property owner hereby authorizes
Name Street 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.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix.2):
If buildin is less than 35,000 cu.ft.of enclosed s ace:and or not under Construction Control then check here❑and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
S CC)k-� _�F)`v4e cA/ 6Q3 -1�5^ 1�,-7n S-1oJ tcowcc, ,r-
Nai (Re strant) Tel? ho p. No. e-mail address Re 'stration Number
10!! �oo�ti c �.-` �c t�ta� � i+- 0 36Z(� c q—(v _a 0
Street Addres City/Town State Zip Discipline Expiration Date
10.2 General Contractor
cos
Company Name
Name of Person Res onsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
l(P`70 S o r C CAA C, L P,(e-4
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOI:KERT COMPENSATION INSURANCE AF.FIDAVf1` 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 ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
1.Mechanical (FfVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 4 G d p 60 (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 f my knowledge.and understanding.
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Please print and sign name Title Telephone No. Date
(6of4 4'rrc Gc�u-, al rF o 3 a G
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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THIS PLAN IS BASED ON THE REFERENCED
PLANS, DEEDS AND THE RESULTS OF A FIELD
YAP Of"H DAN/EL J. MACDONALD SURVEY AS OF THIS DATE: NO CERTIFICATION
PA TRICIA MILBURY /S INTENDED AS TO PROPERTY TITLE OR AS
14 , & TO THE EXISTENCE OF UNWRITTEN OR
G�een�ow� r'0 KARYN A. CLEARY UNRECORDED EASEMENTS
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1 HEREBY CER 17FY 7NlS PLAN CONFORMS
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AM ���------ ----"' 38.42• 4' CLF TO THE RULES AND REGULA 77ONS OF THE� REGISTERS OF DEEDS OF THE COMMON—
WEALTH OF MASSACHUSETTS
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LOCUS PLAN
FOR REGISTRY USE ONLY
SCOTT M. UVA
PA TRICK D. & & / CERTIFY THAT THE PROPERTY LINES SHOWN ARE
DEBORAH A. MARIFLOR T. MAUL/T--UVA THE LINES DIVIDING EXISTING OWNERSHIP, AND THE
LINES OF STREETS AND WAYS SHOWN ARE THOSE
FOLEY OF PUBLIC OR PR/VA TE STREETS OR WAYS ALREADY
_ESTABLISHED AND NO NEW LINES FOR DI VISION OF
z EXISTING OWNERSHIP OR FOR NEW WAYS ARE SHOWN.
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� DWELLING � � DWELLING PLAN OF LAND
DWELLING No. 26
No. 28
No. 30 —
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1. ASSESSORS MAP 27 LOT 360 S A L E M MASS .
2. ZONING DISTRICT R2 >
3. DEED: BOOK 14133 PAGE 133 o w PREPARED BY
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EASTERN LAND SURVEY ASSOCIATES, INC.
qLj 156f' To Dearborn St.
$ - 39.8 ' CHRISTOPHER R. MELL 0, PLS
104 LOWELL ST. PEABODY, MA. 01960
(978) 531 -8121
GRANITE cuRa SCALE: 1 " = 10' JUNE 209 2000
UPHAM STREET
=6�_ - ML
0 5 10 20 30 40 A:93
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