65 BOSTON - BPA-11-211 COMBINE 2ND & 3RD FLOORS 1 . The Commonwealth of Massachusetts
Department of Public Safety
` 'w,y��•/ \la>achusctln State Sodding Code 4%80 C\IRI Sra'rnth Edition
�\ City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
t This Section For Official Use Onlv)
Building Permit Number: Date Applied: Budding Inspector:
SECTION 1: LOCATION IPlease indicate Block a and Lot a for locations for which a street address is not available)
GS S0.lefr\ yntr 7
Xu. and Street C it\• /Town Zip Code Name of Building oil applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair❑ Alteration ❑ Addition O Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Changeof Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No O
Is an Independent Structural Erigmeeri.nA Peer Review r u ? Yes O No.O
Brief Descri tion of Prupu,ra� Work: tr 00r
// V, H o0
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) O
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Flours/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 O A4❑ A-5❑ 1 B: Business O E.- Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: HI Hazard H-1 O H-2 O H-3 O H-4 O H-5❑
f: Institutional 1-1 ❑ 1-2 O 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2 ❑ R-3 O R4
S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Uss O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ ISO IIA ❑ 1100 IIIAO IIIBO IV 1 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:
Pubbcet"' check tloutatde F6.ual Luna•❑ Inalic.1te munictpala A Irench wdl not be Ltcen.ed Ui.p,.d Site ❑
I'n Valc❑ or indenolr Zone: nr un•ire sc.Irm ❑ nqu:rad ❑or trvnch ur �patiA:
permit t.enclosed O
Railroad right-of-way: Hazards to Air.Vavigalion: \1% I lnb•n. t ..........•o i It.. ••. I'n••r-
\, t .\1.1•bi.dda• k ;truoure,r�Ihm.urpurt.,p1•rnach array I. their re%ianv cnmplc6•aL
r l ,n, it n• Ifud.(cndu'•d ❑ )V.❑ nr.X.,W )' O \n ❑
SECTION 8:CONTENT OF CERTIFICA TE OF OCCUPANCY
1 .hti„n u11 . Jr. _—__ L-V ld' rul•l.l'. fa peat lundructum: occupant L.•.id pa•r I In.n
I>. c. Iha•buil,ln,r;:•main.m til,nnkler?,.la•m` ?prclal 11pulauun.
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Nam•.wd .-�{a-(�1rr�/yea Pr l+uric-Owner
� AA l'Y -r�g
.Name Wrint) .Nu. and Sirart Cth/ Town Zip
Pr, h rr 6pta t Inhtrmouun:
'?7
Title Telephone No. (busori r-) relrphonr No. (cell) a-mad aaldra•>s
11 a ±l+lt.al��lthe)+nrprrla• oa„ ^ �/ t rrrrby author
�.61.3 �r� \ Ls
L0—7---5 S L " VG^ Q
Name ( Slrm Aa a rss* City/Town Stair Zip
to art un the +ro +s•rtc uw ner'+behalf, mall matter*relatic-r to work aut h,rncrd by this but Win • perm It a + +bca tton.
SECTION 10.CONSTRUCTION CONTROL (Please fill out Appendix 2)
(11 building is Iv**than JS,UW cu. It.of vnd.wJ< ace and/or nut under Comiruction Contnsl then check hen O and Flu Svc bon 10.1)
10.g1�Reegiis�tee�red`Pro/fessional Res onsibllee for Connsttruction C�onnttrol
Name(Registrant) r Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Co=64ame: 99 tid.\o csSL
Name of Perwn R unsi Ie for Cun ern � (.ic�se No. and Type if�pplicabblle
Street Address t City/Town itSStilatttee- Zip _
Telephone No. (business) Telephone No. cell e-mail address --
SECTION 11:WORKEEW CONWENSA17ON INSURANCE AFFIDAVIT(M.G.L c. 152.§ 25C(6))
A Workeri 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
and Materials) Total Construction Cost(from Item 6) =f 7 J CK.70
1. Building f BuildingPermit Fee-Total Construction Cost x�(Insert here
2. Electrical f appropriate municipal factor) -f�,�.
J. Plumbing f
4. Mechanical (HVAC) f Note-. Minimum fee-f 5 (contact municipality)
5. Mechanical (Other) f Enclose check payable to
6. Total Cost f 2 QC70 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
tiv c•rtlrnnK my name below, I hereby attest and the pain*an �enaltie*of perlury that all of the inhnmabon contained in this
a)+plic.tnnn is true and accurate to the b"l of m knus Iralgr a undrrstanaling.
n � q,2& �0 � 7 u
Ple.,,a•prn rt and "gn to mr I f r_ Talc)+hone No Dale
i S ��r1c`/l e st. C- G
�tn•ct \JJrc�• C'ttci T. cn of Lry+
i %lumcipal Inspector to fill out this section upon application approval: o (/
Name. I +tr