19 BEACON ST - BPA-13-718 RESIDE The Commonwealth of MassachuLr -Family
t
Department of Public Safety
! r ./ \Ie..adnncu.Slaty Omldml;l+�drl•-BUCViIi)Sa•rrnlh !
City of Salem
BuildingPermit Application for an Buildingother than a I- wet 'n
I rhos Section For Official Use Only)
r• Onddtng I'enmt Number: Bate Appheaf: Building Inspector.
/ I SECTION 1: LOCATION IPlease indicate Black s and lot a for locations for which a street address is nor available)
\o. and Street C nc /Town Zip Code Name cat 01,111ding Ut epphcablr)
SECTION 2:PROPOSED WORK
It New Construction check here❑car check all thal appl y in the twu ruws below
Exit. Budding Repair❑ Alteraltun ❑ Addition O Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changeof Occupancy ❑ Ulher ❑ Specify:
Are building plans end/or curutructiun ducuments being supplied as part of this permit applicaliun? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? r Yes ❑ No ❑
Brief Description of Pruposad Work: J`tt[ 2JrrS f� lPQ C/
SECTION 3:COMPLEFE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Cruup(s): Proposed Use Croup(s): t'
Existing H. d Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
rTot,'1)fAF11.
uurs/Stories(include basement levels)&Area Per Floor(sq.ft.)
(-+al.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable) ,
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5 13 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2 ❑ 1.1❑ I-4❑ 1 M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑
S: Storage SI ❑, S-2 ❑ U: Utility❑ _ Special Use❑and please describe below: _
SF+root Use:
SECTION 6:CONSTRUCTION TYPE(Check as app cable)
I IA IB ❑ IIA ❑ 118 ❑ IIIA ❑ IIIS ❑ IV ❑ I VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CSIR 111.0 for details on each item)
1 rrench Permit: Debris Itemuval:
i LYater Supply: Flood Zone Information: Sewage Dispmal: ❑
Pubhc Cll ha'CA it"toside FL,-d Gme❑ In.hr.LLr munrcipal ❑ -\ trench wdl not be LKrmc.l Uny,�.al S�Ir
n:quocd Ourtrcnih r.pcatc.
I'ncaN❑ -r utdcnbA Lma•:_ nr can ,tr•r•Irm O
)•rrmtl r cnclu.ral ❑
I Railroad right-of-way: Hazards to Air A'avigation: \I\ I lnl••na t . ...n .....N'' .
V.I I, �truc lure k.illnn.nt)i'rt aV` `in•ich do\t' Iharr t'J'
.n ln.rnl nHuJ.I cnJ •,c.l ❑� }a•.❑ ••r\n❑ lr. ❑ \n ❑ ._�
SECnO_N 8:CONTENT OF CF.RTIFICA rE OF OCCUPANCY
I .htim ,dl •Jr . .__ l-o l•nnry•ni _ f+l'r•a l', u-trua uant ___ ltcCu)•anl l ...al l•or l I—.,
It •,. ihr l•uil.liu+., n+l.un.m �pnnAlrr.l dcm'' .. `p.•ri•J sUpul.tlnn. __ ____ _.______.—_—_
SECTION 9: PROPERTY OWNER AUTHORIZA TION
V.une and Addrv,,ol 11roperle 11..'ner
0"'t A J Ina ., t7 /g�n U _--.--
\.m+e(Print) No-Ind slrvel llh; town Lip
((ropy(% U..nvr Contact Inlormalu
.tide reiept Na (bu.,uii relephune.No. (cell) ,•-m.nl a.fJ n•..
It el+plli.Iblr, Ih/r l rnpert% ....ner hereby Autthorizes
�.�rVl•{u.r 1T+6114L,ii.., y4ke f-i�$.(✓dt !2 1 X [7 a
\'.Ime sheet Andres.+ Gin'/To"n Slate Zip �(
1n act,m the ni •ern ow nvr, behalf, m.dl mmters rulam a it,work.nithorlra•d by Ihi,building •rrmrt.I + dli,rtunl. `
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(11 N111.Ln a Is Ives dun li.MUcu.it of enclosasl •ace and/or not under Conauchun Conlwl Ihrn check here❑and.Ai•V.Inw III II
10.1 Re istered Professional Res -risible for Construction Control
Name(Registrant) Tel u. e-mail address S! Registration Number
/ Y—,h �sf �. ✓As ,l 6'1� CA-
Di if f
Street Address City/Town state Zip scipline Eapiralwn Uatr
10.2 Central Contractor
Cu��I•�ny�Limr: `
Na rpp a Person Rrspnsi�fur Construction JeeLi rn�N and Type if}lpplicable
St ert Address �/ _ ni �p d
f __Ad / s City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) _
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) _$
I. Building $ /p 9 O 7 Building Permit Fee=Total Construction Cost x$ _(Insert here
2. Electrical appropriate municipal factor) _$
3. Plumbing S
.d. Mechanical (H VpC) $ Note:Minimum fee=s (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
h. Total Cost p'ya
$ D � b 0 fJ (contact munici alit )and wrier check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering my name below, I herrbv attest under the pains and penalnes of perjury that.dl nt the Inlormanon a,ntalned in the,
a •phcanorus true and arnirate to the best nt my knit..lydgr.Ind underst.mding.
'L•.�.•prim and ,gn n.urlc•
�( title rcic h Itile
. - .. ldt r ri ncn �fJfe Lit•
V unicipil Inspector to fill out this section upon application approval: _
I Li Ic