15 AMANDA WAY - BUILDING INSPECTION (2) [7 5.7-
The Commonwealth of Massachusetts
/ W::B;ui1din9
Department of Public Safety
Massachusetts State BuildingCode Permit Application'for any Building other an a O e-or o-Famil elling
(Ills Section For Official Use y).
Building Permit Number. Date Iced: - uildin
- SECTION k LOCATION(Please indicate Block.#and Lot#fox loc ions f w ch.a street address is not av . ble)
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 he or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 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 No 0/0" `rl Is an Independent Structural Engineering Peer Rev w r�4cored?```` �1 Ye ❑ No g
Brief Description of Proposed Work: nfUG1� I�1C11) S1Yl(A'P �iJ ��tnQ
SECTION 3:COMPLETE THIS SECTION IF'FMSTINGBUILDING UNDERGOING:RINOVATION,ADDITION,OR
CHANGE IN USEOR 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.fL)
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❑-3 H: Hi Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I ❑ I-4❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R11❑
S: Storage S-1❑ S-2❑ U: UHEty❑ 1 Special Use❑and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE t(Checkasapplicable)
IA ❑ IB ❑ IIA ❑ lIB ❑ IIIA ❑ IIIB ❑ rv ❑ VA VB ❑
_ SECTION 7:SITE-INFORMATION(refer to 780 CMR 111.0'for details:on each item)
Trench Permit. Debri4Removal:
Water Sup�pl}� Flood Zone Information: Sewage Disposal• A trench��%�'{•not be Licensed Public; Check if outside Flood Zone❑ Indicate municipal wired H or trench or
Private❑ or indentify Zone: or on site system❑ permit is encloRailroad right-of-way: Hazazds to Air Navigation: MA I-liston Commission ReNot Applicable❑ Is Structure within airport approach azea? Is their review com
or Consent to Build enclosed❑ yes❑ or No❑
Yes❑ No
SECTION 8-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? PROPERTY OWNER A`V'I'IIORIZATION (�nu ��( �
Name,and Address Prope Owner # IUo An A l' 1 ' I/ 1 offil. _
Name(Print) No.and Street C' /Town Zip
ZOwner Contact Information:
Xi5WL 7$1- -i A-gq4 & 1 W�4e C 1A
Tide Telephone No.(business) Telephone No. (cell) e-mail addres
If ap licable,the props owner hereby authorizes
_ PO &A oI 0
Name Street Address ty/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building ernit application.
SECTION 10:CONSTRUCIION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu..ft.of enclosed- ace and/or not under Construction:Control then check here 13 and ski2 Section 10.1
10.1 Registered Professional.Responsible for Construction Control'.
e(Re ant) 980 Tel— a tho hone No I mail as Registration Number
.n x
Street Address Ci own State Zip Discipline Expiration Date
102 General Contractor
Company Name I
.UB'�� C 52�1 I ► r] �.ot_ on��UM�V So('
Name of Per n Responsible for Construction Lic No. and Type if Applicable
O `fox * 780 _QL p
Street Address ity/Town � State ` Zip
&���gonL 781-34'�-7021n j_n,.�n_ � 81 1os Y rnns;cn�
Tele hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:rWORKERS'CONMENSATION INSURP. ICE AFFIDAVIT 'G.L.c.152 a 25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ed Affidavit submitted with this applicat ton? Yes❑ No ❑
SECTION.12:CONSTRUCTION:COSTS AND PERMIT FEE'.
Estimated Costs:(Labor. .
Item and Materials) Total Construction Cost(from Item 6)_$
1.Building $ �Q A-�Q Building permit Fee=Total Construction Cost x (Insert here
2 Electrical $ appropriate municipal factor)=$
3.Plumbing $ -
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $ 11 Q
5.Mechanical Other $ nn,p Enclose check payable to
6.Total Cost $ /!/c.v (contact municipality).and write check number here
SECTION'13:.SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I here ttest under th and penalties of perjury that all of the information contained in this
application is true and accurate ti be f r k ledge and understanding.
Z81�k_-9V
Please print and si a Q•H.R � „�� Telephone No. Date
Street Address City own �State
—�1-'Z1Ql-i-�1-(
Zip
municipal Municipal Inspector to fill out this section upon.application:approvah
'Name Date
-L� ��� JJ
/mod `f"``_ (J� U
CITY OF SALEM
ROUTING SLIP
New Construction_
Certificate of Occupancy
LOCATION ATE
ASSESSORS DATE
93 Washingto
ITYCLERKna.•",' ,t *y4i?>a= xtiaa LDDATyE3#`a S �sH *z ,y
3ty.Ati`*',gYe�estr....i. ru
9 ° asQ'gton 5t.
PUBLIC SERVICES DATE
120 Washington St.WATER_ DATE IN
i' I(
120 Washington St. _
CROSS CONNECTIONVW DATE 0((o
Pk� I fVl Slfi
5 Jefferson Ave /j
PLANNING DATE 13
120 Washington t.
CONSERVATION ATE 1�
120 Washington St.
ELECTR:I.CAL °s" s 4 '129"� rD TEE N my- s w
FIRE PREVENTION(Da DATE
29 Fort Avenue
H'E�L"THE>�ae � #�� +e , s D'AT,E:�? 4
21 WashYng on Sty`" -' ;=�
BUILDING INSPECTOR DATE
120 Washington St.
DEC-'11-dUld O'3:UJ FKUI'I:tHbItKN LHNU bUKVtT 1-7 ftl''Jl-J7C✓J IU1101JJ'YP-LL 11 -..�
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Professional Land Surveyors B 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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p p� I hereby certify to the 5&e- '
ZONE: �� LOT AREA: N?ltL_ LOT FRONTAGE: Melll&' Building Inspector that the pro-
posed construction shown conforms
FRONT YARD: 15171 SIDE YARD: 1r)P REAR YARD: 3&1`7 to the dimensional. zoning of
�/'1� 7 Mass.
SCALE: 11 j17G'
DATE:
i F;Y
P crist R.RRFRRFJCF; BK 4UZ �y d,' 7Zl!317
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104 LOWELL STREET
PEABODY, MAS$.01960 4
(508)531-8121