65 BOSTON ST - BPA-11-210 U6 INTERIOR REPAIRS 1
I� / ► The Commonwealth of Massachusetts
Department of Public Safety
\Ia...Ichtvwlls State duwldmg c'❑de l%SU C:\IR)-;e%enlh Edition
City of Salem
Buildinx Permit Application for any Building other than a I- or 2-Family Dwelling
(this Section For Official Use Only)
Building Permit Number: D.ite Applied: Building Inspector:
SECTION 1: LOCATION Moss@ indicate Block 0 and Lot 8 for locations for which a street address is not available)
�5 (3ogk-o.N Sk-OQb Un C0
.Nu.and Street Citii• /Town Zip Gale Name ut Building(it applicable)
SECTION 2:PROPOSED WORK
It New Construct:un check here❑or check all that apply in the two rows below
Existing Building W Repair IN I Alteration O 1 Addition CI Drmulition ❑ (Please fill out and submit Appendix I)
[Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No Or
Is an Independent Structural Engineering eer Review required? Yes ❑ No t8'
Brief Descrjption of Proposed Work: (' 1
\ � , ► e
w
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 7B0 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)A Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION St USE GROUP(Check as a lie bit)
A: AssemblyA-1 O A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5 O d ness ❑ E: Educational ❑
F: Facto F-1 O F2❑ Hs Hi Hazard H-1 13 H-2 CIH-3 ❑ H-4❑ H-5❑
1: Institutional 1.1 ❑ 1-2❑ 1-3 0 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 lie
S: Storage S•I ❑ S-1 ❑ U: Utility❑ I Special Use❑and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a lieable)
IA ❑ IB O IIA ❑ 1180 IIIA ❑ file ❑ IV ❑ VA ❑ VB
SECTION 7: SITE INFORMATION (refer to 780 CNR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Of Indicate mumc:pal$ A trench Will not be Ltcen.ad DisiNi,l Site❑
required❑tor trench ur.pack:
I'naeta•O ur mdrnttA' Lune: ur un.itr�c.iem O permit 1,vndie ed ❑
Railroad right-of-way: Hazards to Air Navigation: \Ll l l,,tnra It...... l'n
\uI \pphcA'ly®' I��truciu ry t.,ihm.urpurt.tpl'ruech erea.' I.their re%ieta complctavl.'
•rt l nt�a•nl L. 14u1.1 enduv'd (] Ye.o ur.\n lC7r 1'e* C3 \u C3
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I dmun,d Coda. L,v(d,,uitl.c rt pe,a Cumirmw-n: Okcup.tnt I.natl per I lour
16r. ihv l'uil.hnt;c.ntiem.tit�pnnAlcr�,.Icm'' >ia•a':al?lii•ulahun.:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Na�IIId a airC.s o 'rnprrly Owner
�k,Q r
.Name(I'rint) .No.and Strait C•ih'/ rown - Lip
Vropeaji Cha r('ll ICI I 1 1111111m: -
Tide Telephony No. (business) Telephone No. (cell) e-ma11.1d,fre s
If ap + lcable, the)prol er v ca ne h rrbv.tut unz ' _ \ M,a
.Name Strevii- ddrrw City/Tu. n State Zip
h1 act on the pro porn oaener•s behalf, in all matters relative to work authonzed by this buildin • permit a + phcation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if building is Iexs thin 33,000 cu.It.of eml,a- %l s ace and/or nut urrler C.Im ru0ion Conlrul then check hen O and Aup Smioun 10 1)
10.1 Registered Professional Responsible for Construction Control
1Nte C90�
Name(Registrant) Telephone No. e-mjd address Regislmtiun Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
]bQnn's
Cu an ;a : 7 CO r r CS&
Name of Pr Res msiblr to slructiun �icbrnse No. and Type if mlicable `C� i�
� 1V
Street Address City/Towni State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WO V (M.G.L.c. IS2 9 23C(6))
A Workerd 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
1. Building f BuildingPermit Fee Total Construction Cost x LL—(Insert here
2. Electrical f appropriate municipal factor)-f C$
3. Plumbing f
4. Mechanical (HVAC) f Note: Minimum fee>•f�(contact municipality)
5. Mechanical (Other) f Enclose check payable to
6. Total Cost f (BUJ (contact municipality)and writecheck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
11v entering my name below, I hereby altrst nder the pains and penalties of perlury that all of the inforVN.,.
in this
application is true anal accurate,to the b of v knuwlrafr r and understanding.
Vlea.c print.Ind �,gn name 111r •epDate
5 4-1,C�o Sfi e.�hYr1 AddrV, C�it%/Taro fr
Municipal Inspector to fill out this section upon application approval: D
N,1"mr Dole