63 BOSTON ST - BPA-11-206 INTERIOR REPAIRS The Commonwealth of Massachusetts
Department of Public Safety
a„ \la..tihuwii,State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number: Date Applied: IBuilding Inspector:
SECTION 1: LOCATION (Please indicate Block a and Lot 1 for locations for which a street address is not available)
No. and Street Cite /rown Zip Caide Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building Repair(d 1 Alteration O 1 Addition O Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy O 1Other ❑ Specify:
Are building plans and/ur construction documents bring supplied as part of this permit application? Yes O No 63'
Is.an Indeliendent Structural Engineering Peer Review required? Yes ❑ No la
Brief Description of Proposed Work:
t lrty� n R -Snve,\v\e RaSP 2 INC,r'
t e5 � f4 h a n_T
i
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) D
Existing UseGroup(s): Proposed UseGroup(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. f1.)and Total Height(ft.)
SECTION 5e USE GROUP(Cheek as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ A-3 ❑ A4❑ A-5 D 1 B: Business O E. Educational O
F: Facto F-1 O F2 O H: HI Hasard H-1 O H-2 O H-3 ❑ H4 O H-5 O
1: Institutional r-1 D 1-2 O 1-3 D 14 0 •M:,Meaantlle O R: Residential R-10 R-2❑ R-3❑ R44r
S: Stora a S-1 O S-2 O U: Utility❑ Special Use O and please describe below:
'Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O ISO HA O Ilea IIIA 13 HIS O IV O VA O VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: `,Trench Permit: Debris Removal:
1'ubhc C heck J nul,iala•Pl,x+d Luna•❑ Indicate municipal(?F '\ trench will not be Licen,ral Di,p o,it Site O
required❑or trench nr,p+at six•:
1'nvaty❑ .or mdenofv Zone: ur un site,c,trm O permit i,vndo,vd ❑
Railroad right-of-way: Hazards to Air..Navigation: xl\ I h�6•rn l ••u+nm•n•n I(n rc+. I'r,
\ul \pp•hc.dle I.tilrui lure+.ithua.urp•url ap•prnach area' I,their re%ivac completed.'
rt l'' •n.aa+t to Iluil.l cni6.vJ ❑ )v,❑ or.\'ofir 1'e,❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
� I ,funm , i l •alr. ____ L.e l�ruupl,i. ra pc ut lou.lruiuun: lkiup•anl Lnaal perlLwr
I6v-Inv bud.lwpiunlan.mSp+nnAlcrSa.Icm' SpavialSUpulauan,
SECTION 9: PROPERTY OWNER AUTHORIZATION -
.Namr and L\ 1drr,c o1 Pr Ipa•r1v C)cvnrr -
Name(Print) No. end?tram C i1v/ rown Lip
I'r�+.j+rrl\ihvn r)c'up act Inlurmaunn: — Coy 1 7
Title Telephone No. Ibusiness) TeIrphone Nit. (cell) e-mad,lddrr.,
If applicable, lhr nlparts• ocrner herrbv authorize+
(tV�IS ��
Name Slrcvt Address City/Town Stale Lip
tll act on the ro +er1v owner's behalf, in all matters relative 10 work aulhonzed by this LlUilding +rrmtt a + +lication.
SECTION 10:CONSTRUCTION CONTROL IPtease fill out Appendix 2)
11f l•uddin is Ics than 35,0011 cu.mot enck-W s ace anJ/ur not under Corotruction Conwl then check here O and.lu hun till)
10.1 Re intend Professional Responsible for Construction Control
1nnt5 Lot- qi 59P 0107
Name(Registrant) Telephune No. e-mail address Registration Number
I�, �r- -I � � S� Mk— al t
Street Address City/Tow State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:
C SQL''
Namt a of Persu Resp ) sible for Cun tructiun License No. and Type if A plicableO l9
Street Address �1 City/Tow State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 12:W V (M.G.L.c. 1S2§ 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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor rr rr
Item and Materials) Total Construction Cost(from Item 6).5 -Tl Od
1..Building f Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical f appropriate municipal factor)=f
1. Pl"'Zin f
4 Mechanical (H VAC) f Note: Minimum fees f__S_(contact municipality)
5. Mechanical (Other) f
Enclose check payable to
6. Total Cost f 4000 (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
_a Hv entering my name below, I hvrrby.0 rst Under the pains and penalties of perjury that all of the information omlained in this
applic III on is true anal accurate 10 the =m.yowl�lgv.ind undrrslanding.
Aro mG C_ h-zV. s�o OCX)7 S011 Coto
IN, I , prat.Ind „ •n name ritir fcicj.+hone..\'o. Dale
.> I c S i�o�lf�� S-t- 7�t.� I� �� � )4 rs
>trc•ct .Wdre" Crty T, Icn S1.1te ZI +
\iunicipal Inspector to fill out this section upon application Approval:
\emr )at