BAKERS ISLAND - BUILDING INSPECTION (25) CITY OF S.U.&m. NL. ss xmus s
• iN BuumLNG DEPAR-r\rmNT
120 W.\SHLNGTON STREET, 3�FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
Kl.\IBERLEY DRISCOLL
MAYOR DIRECTOR
ST.P»JeRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMaSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of ha ler)
The debris will be disposed of in
LL.y'z� G�
(name oYtacility)
(address of facility)
signs o mtt applicant
date
a�ed,r�ra�
1
4.0 PROFESSIONAL DESIGN SERVICES:
4.1 Registered Architect:
Name: Seal and Signature
Address:
Em42
hone: F=
�gisbred ProfessionalEngineers: Oiseaddlanal ahaatt ttnmmany and mw o to Seal and Signature:
Addresm
Telephone: Fax
A[ea,ot_Responsibilily
Name: Seal aril SwMit " .
Address:
Telephone: Fax
Area of Responsibility:
Name: Seal and Signature
Address:
Telephone: Fax:
Area of responsibility:
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C 112 SECTION SIR EXEMPTIONS
(See note below)
Contractor
Name:
Address:
r
a of responsibility:
nse Number. Date of Expiration:ephtne: Fax.
Contractor
Name:- '
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:
Contractor
Name:
Address: '
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:
Note: For portions of work utilizing exemptions of MGL a 112 s.SIR complete the section above.
Use additional sheets if necessary and attach to application.
F
ROFESSIONAL CONSTRUCTION SERVICES:
eneral Contractor
ess:
Telephone: Fax:
Responsible in Charge of Construction:
[77.1
CONSTRUCTION DOCUMENTS -to be prepared by applicant Allk
Item as Applicable
Plans (Note 1 this page) Submitted Incomplete Not Required
.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 HVAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCTION ONLY r
For FWsting_Buildings Proceed to Section 9.0 iv
1,4
Number of Stories above Number of Stories Below
Grade Grade-
Story Height Floor Area Per Floor
Total Building Height Total Building Area Above
above Grade Grade
Total Building depth below. Total Building Area Below
Grade . Grade
Brief Description of Proposed Work:
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION (Newt Construction Only)
USE GROUP" " USE GROUP SUBCATEGORY " CONSTRUCTION
(�as applkbiej (� sap li—
� CLASSIFICATION
A Assembly A-1 ' A-2 A=3 A4 1A
B Business 1 B
E Educational 2A
F Factory F-1 F-2 213
H High Hazard H-1 H-2 H-3 H-4 2C
I Institutionat 1-1 1-2 1-3 3A
M Mercantile 3B
R Residentia[ R-1 R-2 R-3 4
S Storage S-1 S-2 5A
U Utility 5B
Mx Mixed Use Specify:
Sp Special Use Specify:
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction com I to sect o 3.
Existing
Additior► f
Renovation ��r✓i9i Number of Stories Renovated
Change iri Use New
Demolition Existing NRDO
Approximate year of 18,48 Area per floor (sf) Renovated jOQ
construction or renovation 140 New
of existing building
Brief Description of Proposed Work:
Z,✓STerl/ Co.✓crp opiPiy`�.�ts`o✓�F"iTs, PP�bir ae✓lor
�/oor�ja�JT ao .✓eP�Pd, stP�J�Pam�v�tiir ,L/car, it-,orbcP
Gvin/i✓o caY' An.b� dR7¢R,v� /2°,a��r' /m�f, .C� ll��e ,^� �,jprd?
pe use
9.1 USE GROUP AND CONSTRUCTION CLASSIFICATION(Existing Buildings Only)- 1
EXISTING PROPOSED Change. CONSTRUCTION
USE Group(s) in CLASSIFICATION
Use Hazard Use Hazard Hazard
(note$"��)- Group Index `*roup Index index+ (+l as applkaWe)
A Assembly1A� {
y:
S Business 1 B
E Educational 2A
F Factory 2B'
H High Hazard 2d
I Institutional 3A
M Mercantile 38
R Residential 4
S Storage 5A
U Utility 58
Mx Mixed Use Hazard Index
Sp Special Use
Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS (See 780 CMR Appendix L)
Total Constructlon Cost Building Permit Fee Check Number
(1) _(1)x $0.001
9 71011 K +
10.0 AUTHORIZATION OF STATE AGENCY FOR-AGENT TO APPLY FJOUILDI"
PERMIT (when applicable)
I, on beW of the au
Agency or Authority, hereby authorize,
for the building permit for project number,
Signature Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
Name
a &401-e
Signatur Date
12. Certificate of Occupancy required on completion of project? _Yes _ No
Inspector's Notes:
CITY OF SALEM, iNLUSACHUSETTS
BunmLNG DEPART%mNT
130 WASHINGTON STREET, Vo FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
Kl\IBERLEY DRISCOLL
NL IAYOR THoms ST.P[ERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMUIONER
APPLICATION FOR THE CONSTRUCTIOK REPAID RENOVAIWAL CHANG9I9 USS OR
OCCUPANCY,OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Sedift for Oelelat Uw OnV
is Pamlit,ProJsct - O /
Buil(ft''Inspxdw Sl8nsbmw
ktod Daiba: Start Ent
comrt,e+rie: ,
IA SITE INFORMATION
f Locaflon Name: SuldIng:
f
i Property Address:
0
Assessor IMapJSk)dc LoUParcet
24
QWN INFORMATION
2.1 bwmr of land Fi" 4 JQU
Name:
Address: /c3� i9v�
Qe Z 43,0340
Towwwne: to _ 1-j -2 -O
2.2 Owner or lessee of bulk #or s&uaiurs
Name:
Address:
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name:
Address:
Agency Project Number.
Project Manager Name. Tel•
Application for Permit to:
Location
Permit Granted
NBlo�
Approved
Inspector of Buildin