22 BECKET ST - BPA-2010-839 PT ROOF REPAIR i - i(f• The Commonwealth of Massachusetts F .
Department of Public Safety
.\les.,achu.ru.StatvSualdingCode(780CMR)SeventhEdition
(� °1 City of Salem
Vo Building Permit Application for any Building other than a I. or 2-Family Dwelling
(This Section For Official Use Only)
Bu(ding ('ermtt Number: Date Applied: - Building Inspector:
SECTION 1: LOCATION (Please indicate Blocks and Lots for locations for which a street address is not available)
No.and Street City /Town Zip Gale .Name of Building(if applicable)
SECTION 2:PROPOSED WORK
It New Construction check here❑or check all that apply in the two rows below ,
Existing Buildin(,-6" RepaiCQ4 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
ChangeofUse 0_1 Change of Occupancy O Other O Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineer(ng�r Review rryuired? Yes ❑ No�
Brief Description of Proposed Work: - �1. 2 47 )..-. iQ»,� `z_s j2. .,,
SECTION 3:COMPLETE 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 Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ A-3 ❑ A4❑ A-513 - B: Business ❑. E: Educational ❑
F: Facto F-1 ❑ F2❑ H: HIerca Hasard H-1 O H-2 O H-3 ❑ H-4 O H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1.4❑ M: Mntile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
- -S: Storage S-1 ❑ S-2 ❑ - U: Utility❑ Special Use O and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ 1 IV ❑ I VA O Ve O
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: DERemovahe: .Public❑ Check it outside Flood Lune❑ Indicate municipal ❑ A trench will not be Ltcente❑1'nvate❑ or indentiA' Zone oron.ite>%,tvm O required O or trenchpermiti.enclo. 1 ❑
Railroad right-of-way: Hazards to AirNavigation:N,,I Apphc.1ble❑ I.titruclure tcnhut aopurt.tppn,ach,yea.• 1. (heir review cto llmldvticlov.l O Yc.❑ urNuO la•+ ❑ NSECTION B: CONTENT OF CERTIFICATE OF OCCUPANCY
lditt .d G,dv: ____ L,e l�n nil•t�l: rt pe ut Cun.lnation: lkcupant Lund per flou
IN,,- the boil.hog tonLon.in<prinkler?t,lem` �peaal?hpul,thun.:
SECTION 9: PROPERTY OWNER AUTHORIZATION
e.
N.tmv and .\.ldrrss��l Property Owner
Name(Print) .No. and Slrvet Cily/Town Zip
I'nrperty lhvnrr l-intact Inlurmahon:
Title Telephone No. (business) Telephone No. Icell) a-maul addrass
if applicable, the property owner hereby authurizes
Name Street Address City/Town State Lip
tar act on the ro xriv opener's behalf, in all matterx relative hr work authorized by this building permit a p plicaIion.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if building is lass thin 35,000 cu. It.of endosasl space and/ur not under Gm%truction Control then check hen O and kip Section I11.1)
10.1 Registered Professional Responsible for Construction Control
6,�z��o-r 1ao8(I
Name(Rrt��istrant) _-Telephone No. e-mail address Registration Number
�� "zrl a t bm c) Any
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cum Name: L Azd 2q.7 L-�
Fany noj CJ
Name o=esponsible for Construction License No. and Type if�Applicable
�Str�epet�Ad,dress -�p City/Town State Zip
Telephone No.NoNo.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS! E INSURANCE AFFIDAVIT(M.G.L.c.152.011 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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =S
1. Building $ Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)=S
3. Plumbing S
4. Mechanical (HVAC) S Note: Minimum fee=f (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6. Total Cult f D I� � (contact munici alit )and write check number here
SECTION 3:SIGNATURE OF BUILDING PERMIT APPLICANT
lly entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is trace and accurate to the best of my knowledge and understanding.
f �Dbbvsc cI'�?S S�lg- c7
I'leale print.end .I •n nam � ritle releph -v- 'u. ate
�Ira•cl .\.hln•s tp
/y
%lunicipal Inspector to fill out this section upon application approval:
Name I)sue