15-17 BOSTON ST - BPA-2010-125 ROOF The Commonwealth of Massachusetts
f; I, Department of Public Safety
-,.:•f \Lt SsachusC1ts State Building Code(780 CMR)Seventh Edition
City of Salem
^ BuildingPermit Application for an Buildingother than a 1- or 2-Family Dwellin
JL\\1 (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
\I\ SECTION 1: LOCATION (Please indicate Block M and Lot# for locations for which a street address is not available)
1; - I ✓�tzSTn f/ ST 5 4LF�� �D/9/
.N'o. and Street CitY /Tow'n Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
If New Cunstnictiun check here❑ur 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 ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application?- Yes O No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: REIK e D1-/ Qp — ' g- p� 1
�r2 F�sr . A.- ReljP-ac At i- i�
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 Floors/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 ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-I ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
L• Institutional 1-1 ❑ 1-2❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3 ❑ R-4 ❑
S: Storage S-1 ❑' S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111B ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Lone Information; Sewage Disposal: Trench Permit: Debris Removal: ".
PIIbIIC❑ Check if ouhide Flood Zone ❑ 1ndIC.Ite municipal ❑ A trench will not be Cicen.ed Di*posal Site ❑ '
I'ri va to❑ or indentifc Zunc•: or on Site sestem ❑ required ❑or trench or.pecifs':
Permit is enclosed ❑ _
12ailroad right-of-wav: If to Air.Navigation: \I:\ i;.h aii c. ,nnmi��i,m Rrcir • I'r„r,..;
\, 1 :\ppiCahe❑ I.St(uitore cr tlhui airport appruadi art•a' I. their rrc:eic Cumpefed'
,�r Cnmrnt 6, Build CnJ,-,�cd-❑- -- �l'e* ❑ �:r y"o❑
. 1'es ❑ \u ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I.Jition „I G'de: _ L,e Gnniplrl: Fv pe of Cunnll'uchon: ()CC11pant Load per Floor:
the bwldinl;Conl.un,m Sprinkler}c.tem.' Special Stipulations: n
I�� �-��I d, rL. U-C� (in
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Nome and Address of Prupe tv Owner
Name (print No.and Street City/Town Zip
Properh•Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the pro ierh owner's behalf, mall matters relative to work authorized by this buildin • permit application.
SECTION to:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,tx)O cu. ft.of enclosed space and/or nut under Construction Control then check here❑and skip Section I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Numberg„�$ O9
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
d&101�5 rO�f/� i d�
Company Name: & y � 7 3 -
N,3me Person Responsible lu,Constrtfction License No. and Type if Applicable
Street Address _ 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 signed Affidavit submitted with this application? Yes❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item 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 $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) / $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ e� (contact munici ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
—� - Title Telephone Xo, Date
Please print and >ign name
it rcet :\ddres City/Town S to Zip
Municipal Inspector to fill out this section upon application approval:
Name Date