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11 AMANDA WAY - BPA-13-300 NEW, SINGLE FAMILY HOME .i./� ♦ �`////}} (//J� Jy�T ��/yam ///(��//////�{f� The Commonwealth of Massachusetts Department of Public Safety 0o Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number.. - Date Applied: ,Building Official• SECTION k LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) U No.and Street City/Town Zip Code Name of Building(if applicable) 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❑ I Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy "❑ Other ❑ Specify: `, Are building plans and/or construction documents being supplied as part of this permit application? Yes Iff No ❑/QtJ F�1 Is an Independent Description fStructural Proposed rop d Work:ering Peer Rev-*w re d?��) n��ahnq, 4l Brief Descri tion of Pro Work: rjp(1 f UC J, @ YYII V l 1�� 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 CUR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING$EIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) CA/0 IVINAK6F SECTION S:USE;GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ It- High Hazard H-1❑ H-2❑ 11-3 H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-1 R-2❑ R-3❑ 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) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ I VA ❑ VB ❑ SECTION 9:SITE INFORMATION(refer to.780 CMR 1110 for details on each item)- Water Supp1 Flood Zone Information Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone❑ Indicate municipal A trench not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required or permit is encicl trenchosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Pru ess: Not Applicable❑ Is Structure within airport approach area? Is their review comple ? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No SECTION&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 d Address f Prope Owner T_ Pc� x g80 Lin tx1A , mR —oafo Name(Print) No.and Street C' /Town -- - Zip Proper Owner Contact Information Title Telephone No.(business) Telephone No. (cell) e-mail addres If applicable,the properl owner hereby authorizes P O. N)( `l8� L MA oigg Name Street Address ty/Town State Zip to act on the ProEerty owner's behalf,in all matters relative to work auffIc perndt application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) budding is less than 35,000 cu,ft of enclosed space and or not under Construction Control then check here.13 and skip Section 10.1 10.1 Re 'stered Professional Responsible for Construction Control - �� 791-334 -98n +nul' Tele h\'eN�N.�+o- Iail as Registration Number Street Address Ci oT wn State Zip Discipline Expiration Date 10.2 General Contractor - - - Company Name I B 01 iBiase- CSt2" 149 Con struAnn,% V s©C ame of Pe n Responsible for Construction Lic No. and Type if Applicable . ®. . x * 78O P mpf Ql.°ly_O Street Address /Town State Zip &-3[- qSR� Z81- 4 4702�_ In ' 1 i st 6 5 nm Tele hone 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 Accident most be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the i affiance of the building permit. Is a signed Affidavit submitted with this application? Yes lb/No ❑ SECTION M 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 $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact mu'rdity)" 5.Mechanical Other $ _ Enclose check payable to 6.Total Cost $ �a//1�. (contact municipality)and write check number here SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereb t under the and penalties of perjury that all of the information contained in this application is true and accurate to st m o e and understanding. Please print and sig,�x#78A Q.F}.{tr L Ti qhofip _ _ _Telephone Date Street Address CJU Ci own JYSttatte Zi Municipal Inspector to fill out this section upon application approvalgr Name Date CITY OF SALEM ROUTING SLIP New Construction ✓ Certificate of O�cccupancy' LOCATION J d 'E ASSESSORS DATE / Z 93 Washington St. s i a 6 z c C PUBLIC SERVICESQ DATE C41LC (v 120 Washington St. WATER k/ DATE L 120 Washington St. CROSS CONNECTION ---1 IODATE 5 Jefferson Avew2t�1",V PLANNING",.0 , ) _,, ATE 120 Washington St. CONSERVATION TE 120 Washington St. FIRE PREVENTION lit ' DATE l7i 29 Fort Avenue h ngg on U BUILDING INSPECTOR E 120 Washington St.