65 BOSTON ST - BPA-11-209 U5, INTERIOR UPDATES The Commonwealth of Massachusetts
I Department of Public Safety
t+„ \lanctchu,em,State Building Coale 1:80 C\IR).Sva'enlh Editlun
City of Salem
Building Permit Application for any Buildinlit other than a I- or 2-Family Dwellin
1 rhis 5ectiun For Official Use Onlv)
Budding Permit Number: Qrtr Applied: - - Building Inspector:
SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not available)
CIS V--X-Fa01'0 S-k-
.\u. .1 red tit met Cih• /Town Zip Coale Name ul Building (it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or cheek all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration O 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur cur»truction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required_?a O Yes ❑ No
Brief nption of Proposed Wor e
LAVLI n n 2
V�
_ 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 UseGruup(s): Proposed UseGroup(s): Y
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. if Fkwrs/Stories(include basement levels)&Area Per Floor(sq.It.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 8: USE CROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-S❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi Hazard H-1 ❑ H-2 O H-3 ❑ H-4 ❑ H-5❑
I: Institutional I-1 ❑ 1-2 ❑ 1.3❑ 14 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-•11�
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB Cl
SECTION 7:SITE INFORMATION frefer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check tl iubtdv FL+,J Gma•❑ Indicate mumitpal .\ trench will nil be Lrcen.eal Dispar,l'4ile ❑
1'ri%me❑ or indcntily Zarne: it.,n.rte rc,tem ❑ required❑ur trench nr �i•a ally:
permit r.a•nclu.eal ❑
Railroad right-of-way: Hazards to Air.Navigation: \Id l6�o•n. l ••in nrt.•u•dllr...... I'o•..
\. I \ h:.t Pla•fi� I.hlruc lure it rthltt•ur v-rt.t • •i ach are.' I. their read air
. 1•P ) )i c c.un)•Iclu•aI,
•a l 1•n'avn 1" lit, l.l"'Id. ,•,1 ❑ l r. ❑ or.No a, 1b❑ \n ❑
SEC"rION 8:CONTENT OF CERTIFICA,rE OF OCCUPANCY
L ra lkcui•anl i•a•r l 6n.r'
INw, Ihvl•w, Lbnp:nnLun.m;pnnAlcr?a.la•in` ?pedal?ni•ulanan.:
Kam-- ���'��-� •} - �"����� �
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Na urd hlry c 1, erly Owner
.Name(Print) .No. and Street City/ rown Z,p
1IrnF tV 0% as r t• Iact lurm. Ion:
Title Telephone.No. Ibusanrss) Telephone No. (cell) a-mad adclnms
If a shcablr, the pna�rnv uw nvr hrrrbv .I hurl . 2 9
st
Name St r41 Add City/Tow State' Zip
t, .Ice un the ro +a•rts ow racer"s behalf, in all maIter*relah%r to work authonted by this building wrmtt a + shcation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
lit building is It,%thin 35,000cu.It.of vnvha. J> ace.and/ornof under CoroYruction Control then check hen Oand,lup Sixitun I0.0
10.1 Re istered Professional Responsible for Construction Control
nr � uNNyy� S)�Sga 009?
Name(Registrant) Telephone No. email address Registration Number
Street Address City/Town State Zip Discipline Expiration Date'
10.2 General Contractor M'
l )KV `us
Cuntlyalttllv�al
Name of Prr n ejx)r able fur o tr boas License No. and Type if plicable
Street Address l City/To n State Zip
Telephone No. (business) Telephone No. cell - e-mail address
SECTION 11:WO AFFIDAVIT(M.G.L c. 152. 25C(Q)
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 4-
Item and Materials) Total Construction Cost(from Item 6)=S ,oe)o
1. Building S Building Permit Fee-Total Construction Cost < < (Insert here
12. Electrical S appropriate municipal factor)a f�.
3. Plumbingf
4. Mechanical (HVAC) f Note: Minimum fee.S�(contact municipality)
5. Mechanical (Other) f Enclose check payable to
6. Total Cost f ('x7C,, (contact munici alit )and write check number here a
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hrrrbv attest under he' .iris an +rnal6rs of perjury that all of the information contained in this
Application is true and accurate to the best of my narsv edge a mderstant ing.
q7?r d 0 I lei c
I'Ica v printja}I .q;n _ vim I�de' G•lepho ne Nil, Date
�trcvl . ddres C rtt'i To 'n r Ip
3fuuicipal Inspector to fill out this section upon application approval• A4