10 AMANDA WAY - B-13-0572 NEW, SINGLE FAMILY HOME y�
W
N The Commonwealth of Massachusetts
(I Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section Fopf5'�ial Use Only)
Building Permit Number. Date Applied: Building_OfficiaL•
SECTION 1 LOCATIO (Please indicate Blo an Lot#for locations for which-a street address is not available)
9b � �
o.end Street City/Town Zip Code Name of Building(if applicable)
_ SECTION 2-PROPOSED WO
Edition of MA State Code used If New Construction check here or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/Q!J f%)
Is an Independent Structural Engineering Peer Rev' w required (� [ ( Ye ❑ No 41
Brief Description of Proposed Work: nstfU� A �) S1fl�P. t@mi1`/ AlinQe
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 4c 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) Oc�✓U F
SECTION 5.USEGROUP(Check as applicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ElB: Business ❑ E: Educational ❑
R Fac F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 H-4❑ H-S❑
I: Institutional I-1❑ I-2 El1-313I-4❑ M: Mercantile❑ R: Residential R-1 R-2❑ R3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
TA 13 IB [3 IIA E3 IIB ❑ IIIA ❑ HIB ❑ IV VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 fordetails on each item)
Trench Permit Debris Removal:
Water SuppI Flood Zone Information Sewage Disposal: '�t Licensed Disposal SiteIV
Public;7 Check if outside Flood Zone❑ Indicate municipal A trench 0l notbe P
required�f or trench or
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I-lisloric Commission Review Process: li
Not Applicable❑ Is Structure within airport approach area?
Is their review comple d?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No
SECTION 8-CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:-_�_Use Group(s): Re& Type of Construction: Occupant Load per Floor.
Does the building contain an Sprinkler System?:—00—Special Stipulations: ./
y
SECTION 9-PROPERTY OWNER AUTHORIZATION
Name nd Address Prope Owner
T. �� xg8o U ,A , SIR opfc)
Name(Print) No.and Street C• /Town j Zip
Property Owner Contact Information: ,
TU �i5 osp 7�1 �'I�$9. 781-�`�0 21n ' @ etc tv\
Title Telephone No.(business) Telephone No. (cell) a-mail addres
If applicable,the proper owner hereby author O
r P MA_ot _0
Name a Street Address ty/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill orit Appendix 2)
building is less than 35,000 cu.ft:of enclosedspaceand/or not under Construction Control then check here O and skip Section 10.1
10.1 Re •stered Professional Responsible for Construction Control -
Iyant�(Re nt) # o Tele hone No lmail as Registration Number
Street Address Ci own State Zip Discipline Expiration Date
102 General Contractor
CName
TZI -b3u e CJ-1-?n on.S0hff4 Sof-
ame of Pe n Responsible for Construction (�Lic No. and Type if Applicable
# 78Q + 01.40
Street Address /Town nState I Zip
&l - �4�-7021 in+o6 is L6rn .S. cern
Telephone No. business Tele hone No. ceIl e-mail address
SECTION 11;WORKERS'COMPENSATION INSURANCE AFFIDAVIT G.L,c.152.§25C(6))
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated
Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
Building $ 4
1. 6 Building Permit Fee=Total Constriction Cost x (Insert here
2 Electrical $ ,-QQk� appropriate municipal factor)=$
3.Plumbing $ �
Note:Minimum fee=$ (contact munici ty)
4.Mechanical (HVAC) $ UO
5.Mechanical Other $ i / � / �
Enclose check payable to i 1� `1
6.Total Cost $ QO� (coct vnicipali and write check number here
SECTION 13:SIGNATURE' BUIL ERMIT APPLICANT
By entering my name below,I here a t under the and ties of perjury that all of the information contained in this
application is true and accurate e t ge a derstanding.
Please print and sig arm iry, ,C780Q•H• ` Ti __y„,„Telephone No. Date
Street Address Cit}y own State --(��Zllip�-C-,~!v, \
Municipal Inspector to fill out this section upon:application approval:
Name' Date
JAN-7-2013 19:37 FROM:EASTERN LAND SURVEY 1-978-531-5920 TO:17813390111 P.1
BIZ 7'?S ZZ
Professional Land Surveyors $ Civil Engineers
ESSEX SURVEY SERVICE 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PIAT PLAN OF LAND
LOCATED IN
MASS.
larzz
/
L L7ZI n. q!+ ie LGr Z3
75�
�14v
I hereby certify to the
Nil Inspector that the pro-
ZONE:17 ) LOT AREA: A.'t 4r LOT FRONTAGE: kk' posed construction shown conforms
to the. dimensional zoning of
FRONT YARD: /iFT SIDE YARD: ID/T REAR YARD: JG/ `j9�cs�' Mass.
SCALE: I _ NOF eras
DATE: J+�+,". � L:J % -i ,per CHlUSiOPHER Giv„
REFEUXE: PG HK 4GL PG 7,1 Christopher R. p1j3177,0 H
104 LOWELL STREET
PEABODY, MASS.01960 ><
(978)531-8121
fig - a3� �
CITY OF SALEM
ROUTING SLIP
N,ew Construction
Certificate of Occupancy
LOCATION la AMa-4,,4 �z4DATE
ASSESSORS DATE l 3
93 Washington St.
CITYCI ERKtagi° k .a, 4 „ter asD47 E:77196.0K
asfligton J[�x va x.
y
PUBLIC SERVICES ATE (f(e1(3
120 Washf ton St.
WATER DATE LwIj
120 Washington ,,// 1`
CROSS CONNECTIONLL6 DATE ( to lS NII � 'lb'llY(sfl�i:. s7, �
5 Jefferson Ave
PLANNING a E- DATE
120 Washingto St.
CONSERVATION DATE
120 Washington St.
EL•ECT Ill_GAL,
F . ton " ' D' m " 5 r� wais
a a tie
FIRE PREVENTIO DATE -2-o S
29 Fort Avenue
1'2HLLN�ashr gton St. '"'"'
BUILDING INSPECTOR DATE
120 Washington St.