20 AMANDA WAY - BUILDING INSPECTION (2) 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: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
91�
No.and Street City/Towd Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here Vor check a6 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 ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as pan of this permit application? Yes Or No ❑ &1
Is an Independent Structural Engineering P�qr�Review / � Yes Ni�L[y Brief Description of Proposed Work: �✓
i
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 C BUILDING HEIGHT AND AREA
Existing Propose
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) S'
Total Area(sq.ft.)and Total Height(ft) S f
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-I❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 -4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 14❑ NE Mercantile❑ R. Residential R-1 R-2❑H R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill IIA ❑ IIB ❑ IIIA ❑ M ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information Sewage Disposal: Trench Permit: Debris Removal:
Public Ir Check if outside Flood Zone❑ Indicate municipal A trench ot be Licensed Disposal Site
LY
required I or trench or spec' : L
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ BH s/ e
Railroad right-of- Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicablewa Is Structure within airport app5Wh area? Is their review complete ?
or Consent to Build enclosed❑ Yes❑ or No I Yes❑ No
SECTION 8: ONTENT OF CERTIFICATE OCCUPANCY
Edition of Code: R rl Use Group(s): Type of Construction: L°B• Occupant Load per Floor:
Does the building contain an Sprinkler System?:_ +4 Special Stipulations: ��
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and
Addressofl/ /g /P 1 . �rls
Name(Print) No.and Street City/Town Zip
Pro pe y wne C ct ormation:
r
T' e Telephone No.(business) Telephone No. (cell) e-mail address
If ap ab the propelwrier hereby au rues
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 0 and skip Section 10.1
10.1 stered Professional Responsible for Construction Control
tr�t Telegh^on _o.// V address Registration Number
Street Address Of,City/Town State Zip Discipline Expiration Date
10.2 General gontractor
-GK�QG .y �J /+ � 1
Comp Y i e / CS 71 y / Sf S'a
Na Ia of erson R ponsible for Construction Li e o. d Type if Appbc le
!�� . X` � n oG ��
Street Address Ci /Town State Zip
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 Accidero must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the' ante of the building permit.
Is a signed Affidavit submitted with this application? Yes UK No ❑
SECTION I1 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 $ ffo
4.Mechanical (HVAC) $ aegv 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 hereby att-stun a pains and penalties of perjury that all of the information contained in this
applic o is true an cur to the best of o e ders ding.
Ple�ri;►�and 6jgn r �� �tFle . eleph Date
Street Address City/Town State i
Municipal Inspector to fill out this section upon application approval: l
Name Date
CITY OF SALEM
ROUTING SLIP
New Construction l�
Certificate of Occupancy
LOCATION ATE L
ASSESSORS DATE ay//�
93 Washington St.
V TVCJLERKs64. �
° � �:ebr,��`�D
��VV�
`93°°�Yashi�gton
PUBLIC SERVICES DATE
120 Washington St.
WATER 1/ �'` DATE
120 Washington St. �T—N
CROSS CONNECTION' ID�TE
5 Jefferson Ave
PLANNING," DATE 1/2.4117-
120 Washington St.
CONSERVATION
120 Washington St.
8"Cataette5t. —
FIRE PREVENTION DATE l�
29 Fort Avenue
�LTl1 au? sit 'D a FED
W�a�IlTn on t. .
BUILDING INSPECTOR "///Yta+ ATE d
120 Washington St.