B-19-1083 - 0005 VISTA AVENUE - Building Permit a The Commonwealth of Massachusetts
Department of Public Safety
," W►� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This on Sectt Only)
For Official Use O. y)
Building Permit Number: Date Applied Building'Official: '
00 SECTION li LOCATION .
Q �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❑ 1 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 Review requir d? Yes ❑ o ❑
Brief De criptipn of Proposed Work:
s
v-
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.) Ut7
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 ❑
F: Facto - F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R- R-2❑ R-3❑ R-4❑
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 ❑ 11 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply:1 Flood Zone Information• Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone Indicate municipal`�j A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: 1 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 E] Is Structure within airport approach area? Is their review coigleted?
or Consent to Build enclosed❑ Yes❑ or No Li Yes❑ No�7
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
0 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 (V
I
Name and Address of Property Owner
ame(Print) No.and Street City/Town Zip 9
Property Owner Contact Information: q9P LI P2k. 1111-- 1
Title Telephone No.(business) Telephone No. (cell) e-mail address U
applicable,the property owner hereby authorizes:
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Nam 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 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here
Otherwise provide construction control:forms see section 107 in the code as required.
10.1 Re istered Professional.Res onsible'for Construction Control(the rofessiorial coordinating 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
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address /3 3 L j o City/Town State Zip
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 13 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 21)4,00
1.Building $ cuo Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 00 appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ — Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $.a ' •Iw (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 print and sign name Title Telephone No. Date
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval:
Name Date
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Dame(Print) No.and Street City/Town Zip
Property Owner Contact In.P rh' PD
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Nam 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 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here
Otherwise provide construction control forms see.section 107 in the code as required.. .
10.1 Re istered Professional Res onsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor t J }
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. c 11 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
Estimated Costs:(Labor f f- f
Item and Materials) Total Construction Cost(from Item 6)=$ r l (
0
1.Building $ o�: .',i G) r (Insert e
�,,. • ;� Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ 1 '�i�' appropriate municipal factor)=$
3.Plumbing $ 71, Qe
— Note:Minimum fee=$ (contact municipality)
4.Mechanical WAC) $
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ e� (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.
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Please print and sign name Title Telephone No. Date
Street Address City/Town State Email Address
Municipal Inspector to fill out this section upon application approval:
Name Da e
k1
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructi'6r f§bpervisor
CS-101660 Ek ir es: 04/18/2020
KEVIN C HYDE � °
3 AUTUMN VIEW , ,
SALEM MA 01970, ��� 3
�qCIL
Commissioner
r
S I�i�s A
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION V/;TA 4Vi5, DATE
I/ASSESSORS4A�& DATE 7
III/// 93 Washington t.
CITY CL DATE
93• ash—in gton St.
PUBLIC SERVICES DATE—`Z /.`
120 Washington St. (l
WATER ' Q DATE 1 l
120 Washington St.
CROSS CONNECTION DU4 DATE
5 Jefferson Ave
PLANING DATE
12 , ashington St.
CONSERVATION DATE
120 Washington St.
ELE CAL DATE
4 afayette St.
FIRE PREVENTION DATE
29 Fort Avenue
;,.11�TH DATE
Washington St.
BUILDING INSPECTOR DATE
120 Washington St.
4 .
QTY OF SDK MASSACHUSEM
BUEEMGDEPARTMENr
120 WASgI<NNGTONSwET,PFLOOR
: IkL(978)745-.9595
KDOERLEYDRISODLL FAX(978)740.9846
MAYOR THoMAs STYmRRE
Dnmcrm OF PUBLIC PROPERTY/Bua DING GDmasslom
Construction Debris Disposal Affidavit
(requiredfor all demolition & renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR,.Section 111.5 Debris,
and the provisions of MGL c40,S54;Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by IVIGL c 111,S150A.
The debris will be transported by:
~ (name of hauler)
The debris will be disposed of in:
(name of facility)
'451 A.Wv �-L tz�
(address of facility)
C
Signature of applicant
(today's date)
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