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14 AMANDA WAY - BPA-13-534 dam. n The Commonwealth of Massachusetts 1 Department of Public Safety 1 \f/ Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Famil we g (This Section For Official Use Only)` Building Permit Number.: Date Applied: Building.Official: SECTION I-LOCATION.(Please indicate Block#:and Lot li for locations for which a street address is nd4 available) 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 F Existing Budding❑ Repair❑ Alteration ❑ 1 Addition❑ T Demoht on ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ,❑ I Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No am Fil Is an Independent Structural Engineering Peer Rev' w re d?`� (l 1 f Ye ❑ No Brief Description of Proposed Work"I CO fUC )veto JIYltA1P @MfIV IJitJP��IYIQ SECTION 3:COMPLETE THIS SECTION.IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE Olt 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.) — . IS)cr SECTION 5:USE GROUP(Check as.applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 Cl A-5❑ B: Business Cl E: Educational ❑ , F. Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 H-4❑ H5❑ I: Institutional I-1❑ I-2❑ I-3❑ Ih❑ M. Mercantile❑ R Residential R-1 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable IA ❑ IB ❑ ILA ❑ 1I1; ❑ HIA ❑ MB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer 780 CMR 311.0 for details on:each item) 01 Trench Permit. Debris Removal: Water Sup Flood Zone Information: Sewage Disposal: A trench w' not be Licensed Disposal Site Public Check if outside Flood Zone Indicate municipal wired 1W, trench or Ali Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Cominission Review Process: 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: 8 Use Group(s): Type of Construction: Occupant Load per Floor. Does the building contain an Sprinkler System?: 90 Special Stipulations: .� SECTION 9: PROPERTY OWNER AUTHORIZATION Name.and AddressgVroverty Owner # Po x gg (SIR oefQ_ Name(Print) No.and Street C' /Town Zip Prope Owner Contact Information: , TU n1 7$133��$. 7$1 ©_2_J,� 1 ° oC�IP •-C Title Telephone No.(business) Telephone No. (cell) e-mail addre If ap livable,the proper owner hereby authorizes P,O. �jC �80 MLLqq_o Name Street Address ty/Town State Zip to act on the property owner's behalf,in all matters relative to work authorizedt�y this building permit application. SECTION 10:CONSTRUC 1ON CONTROL(Please fill out Appendix 2).. building is less than 35,000 m.ft of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Re 'stered Professional Responsible for Construction Control �m�e ' antg>;� ).�ryOo Tele hone No I mail r ss Registration Number Street Address CIVAGWIl State Zip Discipline Expiration Date 10.2 General Contractor Company Name qTbt1I •17ZOS—e CS ?nI �rl •�� on. V Sor sine of Per n Responsible for Construction Lic No. and Type ' Ap livable ® Qs2X # 7g p 1 pickgo Street Address ity/Tow State Zip g 71 -34 - o2 �oCA1 - � M0,s, G0Mg _ Telephone No. business Telephone No. cell e-mail address SECTION 11-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT;M.G.L.c.152 6 25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No ❑ 'SECTION 12•CONSTRUCTION.COSTS-AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ r 40 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ l /QQQ appropriate municipal factor)=$ 3.Plumbing $ - 4.Mechanical (HVAC) $ (IVCY Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ ] (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 thus application is true and accurate st o e and understanding. Aolma T11s�W M Z4 I-90 -- Please print and si Q.H.R.T. Ti Telephone No. Date L M -d Street Address CibjAown State Zip Municipal Inspector to fill out this section upon application approval:. Name Date �(Z795-GO ono bodnoo� G]� o� �Qo�� �oQo Professional Land Surveyors Er Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 PLAT PLAN OF LAND LOCATED IN SALE/ MASS. ZD ti i 1 w A ,\1 OVA V I hereby certify to the Lt f' t Building Inspector that the pro- posedA)! construction shown conforms to the dimensional zoning of FRONT YARD: SIDE YARD: AM-T- REAR YARD: �' v' Mass. SCALE. t t f '`.J 3SNc DATE: Ask" �� ', e'42_" ER P REFERENCE: ) BK 4)Z.. PG JcJ Chr stopher R. Mell-'v 31F W7 Nl, No. 104 LOWELL STREET Fci a yob Jy PEABODY, MASS. 01960 k (978) 531.8121 FAX: (978) 531-5920 - CITY OF SALEM ROUTING SLIP New Construction Certificate of Occupancy LOCATION � ASSESSORS DATE 93 Washington St. g_ IT�YCLsERK � �o�2ei �D TE k; �xwxr: i PUBLIC SERVICESq F\ DATE K V 120 Wash' on St. WATER DATE 120 Washin ton St. �j� f , � CROSS CONNECTION C✓ DATE ivl� �L �rn 5 Jefferson Ave PLANNING O Uo / DATE 12�zo� I Z V 120 Washington St. / LL CONSERVATION DATE / d O �� 120 Washington St. ELECT.RICA,L ��a '=a� �D'�I sF Mks a a eME t�te'St. nn FIRE PREVENTION ;J p, �_ O�a. DATE /a oZI2 29 Fort Avenue V�sFiiiig�toti µt BUILDING INSPECTOR DATE 120 Washington St. F 1Z795-GO n��o brand LnpDo� G � o� ��oa boo Professional Land Surveyors 8 Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD & WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN s�LE�1 MASS. rl/1Yrd h. 7,1 L IJ� I hereby certify to the SIJZI -l' ZONE: /9 >>- Building Inspector that the pro- LOT AREA: q= � LOT FRONTAGE: posed construction shown conforms to the dimensional zoning of FRONT YARD: SIDE YARD: REAR YARD: 5� fs% 5,Y6 ;� Mass. SCALE: DATE: 1.'Ufr t;) 20t�'. REFERENCE: ;!. BK ,4uL . PG 76J Chr stopher R. Meld o PI# 104 LOWELL STREET " PEABODY, MASS. 01960 (978) 531-8121 . FAX: (978) 531-5920