63 1-2 BOSTON ST - BPA-2010-891 NEW KITCHEN CABINETS :4, 1 The Commonwealth of Massachusetts
I, Department of Public Safety
.\lassachuwtts Slate Building Code(780 CMR)Seventh Edition
/�\lJ City of Salem
Building Permit Application for any Building other than a I-or 2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
ww SECTION 1:LOCATION(Please indicate Block M and Lot N for locations for which a street address is not available)
�) !a3%Z Imo- a�an S-1,�. S Alem N1Vk 6 (R7o
.No.and Street allwe-3 Cin, /Town Zip Code Name of Building(if.applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building 19' Repair Alteration ❑ Addition❑. Demulitiun ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other G'Specify: k4c� n �' A6%neA-S
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Cl-�
Is an Independent Structural Engineering Peer Review req /
uired? Yes ❑ No ❑
Brief Description of Proposed Work�apScV��a-1io,'1 0-� nC�u �L��-cln.ert �ah• ne-�S
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 O
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage SI ❑ . S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B0 IIIA ❑ 1118 ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public CT� Chuck if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
Private❑ or mdcnlifc Zone: or.m site scstem❑ required 19 ur trench or specif%:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: �L\ I lia.•ri;c'•nnin i.�inn It....... Prnrc�.:
..\ol Applic.d.le I.Stnichur,cnhua airport approach.arra.' Is their review Completed,
,r l "nt.ent to Budd enclosed ❑ N'es❑ or.M,
1"rs ❑ \u
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
[dnion of(-ode: L.c•Grnupl,l: k pe of Con,truchon: Occupant Load per Floor:
11w,the budding;contmn.m Sprinkler S% teml: Special Slipulaliun : nr
W
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Addrrs+ol PruprrtY Owner
SCc�'G-.7C-T 11 Qom t,a-a4N r-I�a�sk a4 Salem Plc\ oAZo
Name(Print) Nu.and Street City/Town Zip
Properly O%kner Contact Information:
o W r. r -Iv9. 41 1 3
Title Telephone No. (business) Telephone No. (cell) a-mad address
If applicable, the property owner hereby authorizes
k�enl\tS L4118r'U I's -,V. 3e�enitl�_ M� otr s
Name Street Address Citv/Town State Zip
to act on the +ru perty owner's behalf, in all matters relative to work authorized by this building permit a >rlication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,tM)cu.ft.of enclosed space and/or not under Construction Control then check here O and.,k-ip Section I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
)S —X—)ocSGF f{-{ 'fI or l
Street A� City/ own State Zip
q-1$ -'T16-6bef) r\\
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 is uance of the building permit.
Is a signed Affidavit submitted with this application? Yea frNo O
SECTION 12:CONSTRUCT ION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6, _$ 00
1. Building $ oo Building Permit Fee=Total Construction Cost x j I (Insert here
2. Electrical $ appropriate municipal factor)
3. Plumbing $ oo
4. Mechanical (HVAC) $ Note:Minimum fee=$�-�(contact municipality)
5. Mechanical (Other) $ eoOec'oC GS
Enclose check payable to
6.Total Cost $ 6-�306. (contact municipality)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.
cco
Plcasc print and sign name Title Telephone No. Date
Steed Addres
Citsi Tuwn -fate Zip
I
.Municipal Inspector to fill out this section pon application approval: AANN
.Xame Date �