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63 BOSTON ST - BPA-11-207 INTERIOR REPAIRS I �� ;► ' The Commonwealth of Massachusetts Department of Public Safety \Ia,�ichuwlI,State Budding Code I780 C\IR)Secenlh Edi tiun City of Salem BuildinX Permit Application for any BuildinX other than a 1- or 2-Family Dwellin (this Section For Official Use Only) Budding Prrmit.Number: Date Applied: IBuilding Inspector: SECTION 1: LOCATION (Please indicate Block s and Lot a for locations for which a street address is not available) i 63 e)05A0r\ SE N-Em un P Nu.and Street City /Town Lip 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 E.ci,ting Building I# Repair Id I Alteration ❑ 1 Addition❑ 1 Demulftion ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy • ❑ 1 Other Cl Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No 0' Is an Independent Structural Engineering Peer Review rayuired7 ` Yes ❑ No 8" q Brief Description of Proposed Work: C2OWin M®1c� ❑� �',C�QI!' C4,\� ate''( lw jf �`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 UseGroup(s): Proposed UseGroup(s): t Existing Hazard Index 780 CMR 34: Proposed Hazard Index 730 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)dr Area Per Floor(sq.11.) Total Area(sq. ft.)and Total Height(ft.) SECTTON S:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: HI 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 R40 R-2❑ R-3❑ R44B S: Stora ei S-1 ❑ S-2 ❑ U: Utility❑ - Special Use❑and please describe below: Special U.se: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ lea IIA ❑ IIB ❑ IIIA ❑ 11I0 ❑ 1 IV CI 1 VA ❑ VB ❑ SECTION 7: SITE INFORMATION frefer to780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: ,Debris Removal: Public C hack Uuuhide Fhe•d Luna•❑ Indicate municipal if A trench will not be Licenwd Di,po,d Site❑ I'r:caty❑ or indentdv Lune: or on ate,c.tem ❑ required❑ur trench ur.pecd permit :,vnclo ed❑ Railroad right-of-way: Hazards to Air Navigation: I \14 I h.i••n. \ , iaiin..i •„Itruvw I'rir \,.I \pphc.ddcB ' 1, their re%ivac pvnpleted.' •a ( •ni�cnl iuliu dd cndovd ❑ )c•❑ ur No,(if• 1'e,❑ \u ❑ SECTION 8:CONTENT OF CERTIFICA IE OF OCCUPANCY I-.IiW aig ( • Jm ___— Lvl:roupl.l: ri pc ul Cumir\ictwn: \kcup.url Load leer ILnrt I Ili•r. thebuiLluip:oni.unanSprmAlcrS\.icin` ?I•av'ial�Upulaounv SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Adt rv>.r of I'(opvris,Owner _ �C' (h lTQ\11C�I' Name(Print) .No. and ?1net City/ Town Zip 1'ro ly lh re-l .mlacf information: ,A9- 1412 _ Title Telephone Nu. (business) Telephone No. (cell) a-mad acfdre�s II, p phcable, the pro+er1%, owner hereby authorrze:r L l okv OonGE S-F vn © 1q t5 Name k Sirm Addresv City/Tow,t State Zip to acl on the j,r%iferj% ,%%nvr's behalf, m all matters relainv to work authorized by this building permit a p pbcatitin. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buldin is Ic x than 35010 cu.It.of vn,:k-xJ> ace and/ur not under Coaaruction Control then check hen O and ski $satwit I11.11 10.1 Registered Professional Responsible for Construction Control Vfi)R `a-S1O 000 Name 1Rr pi 1frant) Lele�phunr No. e-mail address Registration Number l 11�©t lit t CM V-4 t 1 1 K Street Address City/Towlit State Zip Discipline Expiration Date 10.2 General Contractor Lp,-V\JDM Co par y Name: —� Name of Person Respxtsible for Cunstruction License No. and Type if Applicable 1 G oc,1C-R Qtz ( Qve2�� r,o 19 is Street Address City/ own State Zip 5ctQ ©0O 2 Telephone No.(business) Telephone No. cell e-mail address SECTION 1 AFFIDAVIT(M.G.L c. 132. 23C(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 O No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6) =f 00 0 1. Building f Building Permit Fee.Total Construction Cost z "t_(Insert here 2. Electrical f appropriate municipal factor) 7. Plumbing f 4. Mechanical (HVAC) f Note:Minimum fee.f�(contact muniicciip(allity) co 5. Mechanical (Other) f Enclose check payable to `eJ"' 6. Total Cost f 5,000 (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entnnnK my name 1prluw, I I)FTt y attrt under the pains and penalties of perjury that all of the informatwn cnntanned in this application ry true and.tccura F to tl v bra u' y knowlealtie and undvrstandinK. C z 7 8/j1/ate I'leaw print and +ign name ride Telephone\o. Uaty r S DoD ae 5-L Isev¢dia o 19 [S Street Add .t lei Tu en St.]to Gp 7� %tuoicipal Inspector to fill out this section upon application approval: V \'am I ,t