12 AMANDA WAY - BPA-15-39 NEW, SINGLE FAMILY HOME 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
(This Section For Official Use Only)
Building Permit Number: Date Applied: I Building Official:
SECTION 1:LOCATION(Please indicate Bloc an t#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 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 ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
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 rewired?,`�) I f Y ❑ No f�
Brief Description of Proposed Work: C r1 fUC li' E �O and j - )Wali"O,
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 ProposedG�
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.fL) y Gv
Total Area(sq.fL)and Total Height(ft)
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. Fact F-1❑ F2❑ IL High Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ IC Residential R-1 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA IIB ❑ IIIA ❑ HHI ❑ 1 IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Sup�pllp Flood Zone Information Sewage Disposal: Trench Permit: Debris Removal:
Public l� Check if outside Flood Zone❑ Indicate municipal A trench,�_�"not be Licensed Disposal Site
Private❑ or mdentify Zone: or on site system❑ required®or trench or p
permit is enclosed❑
Railroad right-of-way: I Hazards to Air Navigation MA Historic Commission Review Process:
Not Applicable❑ i 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:_Lq-th_ 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 f Prope Owner
T•� nx g80 L f* , 01(*tc)
Name(Print) No.and Street SW/Town Zip
Property
� Owner Contact Information:rism-L �2L� r,I 78t Q�JI.�Br
Title Telephone No.(business) Telephone No. (cell) e-mail address!
If applicable,the proper owner hereby
r a authorizes
P,0. (�. 0 f
0 I T[O
Name Street Address ity/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)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
ul ajosf, 791334-gS91 C
Iy,�nt(e•('Re ant) r r O o Tele hone No I matt a ft Registration Number
Street Address .JO City.,4Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name II
r�t )I .M(Me' Const c�n.� lMry so(-
ame of Pe n Responsible for Construction s ns No. and Type if Ap licable
�0. �hoX # 780 � MX 0lgy0
Street Address ity/Town State Zip
&- - gBQq �-344-70RD in chi}IAnl" �omP,S, cam
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 siffted Affidavit submitted with this application? Yes❑ No ❑
SECTION 12-CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 1370' Building Permit Fee=Total Construction Cost x (Insert here
2 Electrical $ /S(JU(J appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ 0(f Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �•Q� (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I here�t under the pdiqs and penalties of perjury that all of the information contained in this
application is true and accurate to bes of epage and understanding. 7&
�q
Please print and si ame,' a H.R.T Ti /�Tele hone No Date
P E n L z( 7F J I_d— — 1�Imo- p
Street Address Cit) own State Zi,
Municipal Inspector to fill out this section upon application approval: l�
Name V Date
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Ong 3lq m bnmd S�uf'ny G�DDOA619 39 2M&
Professional,Land Surveyors 8 Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
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ZONE: e(. LOT AREA:/UD/�� LOT FRQNTAGE: ,//G!f/L Building Inspector that the pro-
FRONT YARD: /SGT SIDE YARD: 10f7 REAR YARD: 3& posed construction shown conforms
�" to thezoning dimensional zon of.
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REFERENCE: m 40Z PG stopher R. Me1 o PI 1 1331 '
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104 LOWELL STREET a sc
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PEABODY, MASS. 01960
(508)531-8121 -
FAX:(508) 531-5920
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CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy AA
LOCATION /c2 lb�Vawe& DATE -d-012—
ASSESSORS '^ DATE
93 Washington St.
CITY CLERK , ; § Fn � k DATEs ,� � ¢
J`
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PUBLIC SERVICES ATE JO/loho a
120 Washington St. Wp�L0. OcGT i► O(3gS
WATER CKa- tYLvYa., DATE Akteds fo P.+rJ+or.- Iteau+
120 Washington St. A,ktu % ZA's-0o
CROSS CONNECTION /V l DATE 10110 IM(Z WC5 Yv �tolh p'bpmeJ(u
5 Jefferson Ave
PLANNINGO jjJ .4,tUDATE
120 Washington St.
CONSERVATION DATE/(21 D
120 Washington St.
LECTR48"�aYay Y D w�1-6 mal
FIRE PREVENTI a, ..,.l .a . DATE /
29 Fort Avenue
Ex
Vasli�i5lgton`S"t. �
BUILDING INSPECTOR �/! (LDAT,
120 Washington St. 00