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63 BOSTON ST - BPA-2010-208 REMODEL KITCHEN i The Commonwealth of Massachusetts \' t Department of Public Safety %fasstchuwlls Swir 0udating Code i780 C\IR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1- or 24amil Owellin (this Section For Official Use Only) Oudding Prrmlt Number: Date Applied: 1 Building Inspector: SECTION 1: LOCATION (Please indicate Block I and Lot a for locations for which a street address is not available) 76515 C ,�1-5t 51LIN Un st 3 Nu, and Street 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 ruws below Existing Building t Repair fd 1 Alteration O 1 Addition O 1 Demulition O (Please fill out and submit Appendix 1) - Change ofUse ❑ Changeuf occupancy 13 1 Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes D No X Is an Independent Structural Engineering Peer Review requirrd7 -(n l Yrs ❑ No W Brief Drcription of Proposed Work: \C:71\rl '1' 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 St USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 O A4❑ A-5❑ 1 W. Business ❑ E: Educational ❑ F: Facto F-I O F2❑ LHi Hi Hazard H-1 O H-2 O H-3 O H-4❑ H-5❑ 1: Institutional 1-1 O 1.2❑ 1-3 O 1-1❑ M: Mercantile O R: Residential R-113 R-2 O R-3 O R4 fit• S: Storage 5-1 ❑ S-2 O U: Utility❑ Special Use❑and please describe bviuw: S,ecial Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA O IB ❑ IIAO 1180 IIIAO II18 ❑ IV ❑ VA VBO SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 fordetails on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Perinit: Debris Removal: I'u1+ha. :\ trench wdl not be L:crn.rd D,%,N, .tl Site ❑ fir l'hack tt uutnide F1,".0 G+ne❑ Indicate mrmiopal vO required❑or trench .+r. I'm otv❑ or mdenufc Zone: ur on.ne m,lem ❑ I l acdv: permit t.en clu.ral Cl Railroad right-of-way: Hazards to Air.Navigation: aIA I h.hn. t. onnn�n.n It..m+. I'r.....: Nnl \hldic,tlde h�trua Jura•+rtlbm aopurt apt+rnaah area' L Ihvtr ret ie+c anmplclvd' ur 11 nt�cnt I.+ Ilmld vndo+ -d 0 1 V,0 nr No i� 1'va❑ Nu ❑ SECTION 8:CONTENT OF CERTIFICA rE OF(KCUPANCY L,v t.wupl.r. ra pv.a C on,truitu-n: lkcul•.tnl Load lvr I Lour_- 17.v.thv l•ud.lu+r;c.utlain.ut�pnnllcr„.k•m' �pva'ml�Upulauon.: SECTION 9: PROPERTY OWNER AUTHORIZATION rl1`+eCrt-v Owner Name iPnnt) � ,No.end Street City/ rown Gp I'n�l+rrl the nYr(-+� art Inturmau�m: }� �-�i�7 •1-�' C•T'Q l— __ �W - C Title Telephone No. (bu.mv-0 Trirphone No. (cell) v-maul.tddnos If apt+haeblr, the pn.perty owner herebv aut un[es �ir�ntS LA�n22 l� oalm St- Chi Name Streel dalress City/Towd Stale Zip to act on the +ru +rrh uwnvr',behalf, in all mauvrr relanve-k)work authon[ed by this building +ermtt a + +hcauon. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If building is lass than 75,uW cu.It.of vmka%f s ace and/ur nut under Comtructiun Contrut then check here O and Aup Saatwn I0.1) 10.1 Rejtistervd Professional Responsible for Construction Control ( Iry o, LWk� 'MZ -52Q 0007 Nam x(R� ta o. r-maH ad O1i Registration Numbers \4-2 �� t/ Qn ,,l Cahr Street Address City/Townf State Zip Discipline Expiration Date 10.2 General Contractor 1bQ 4-\1 S L.&N Co=z LrrV,.J K\-J ` A CSS L Name of Pe .y�Q Res unvible for Cunstructitin 1 License No. and Type it Applicable I"�- \�O a..Q ST' - Ug M_ CIS is Street Address City own State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERF COWENSATION INSURANCE AFFIDAVIT-IM.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 O No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor C and Materials) Total Construction Cost(from Item 6)=f J J� 1. Building f Building Permit Fee-Total Construction Cost x IL(Insert here 2. Electrical f appropriate municipal factor)-f—S-S—. J. Plumbingf 3. Mechanical (HVAC) f Note:Minimum fee=f (contact municipality) 5. Mechanical (Other) f Enclose check payable to G©- oO 6. Total Cost f 000 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Ile entering my name below, I hvrebV j st under the puns and penalties of perjury that all of the infurmatrr.n cnnt.uned in this •tpplicaUon is true and accurate tot 6 best of my know •algr and undemanding. Jb"ts LA"Uy , &-c, gz�-.syo oa-7 V- (( 10 I'Ice.0 p�+ nd .Ign n.otlr Title relcpht.ne No. ' 1 e o a -e � O ! ylrvrl Addr,— CO.% T.-tan $fate L + Municipal Inspector to fill out this section upon application approval: Name k17I air