73 BOSTON ST - BPA-2010-512 RPR BURST PIPE a
:(> The Commonwealth of Massachusetts
LlIermit
Department of Public Safety
\Ia.stchuwttsState BuldingCodeG80C%IR)Seventh Edition
City of Salem
Buildin Permit A lication for an Buildin other than a I-or 2-Famil Dwelli
IThis Section Fur Official UseOnly)
ber: D.ur Applied: '2 Budding Inspector.CATION(Please indicate Block Y and of for locations for which a street address is not available)
( SAY 0. (Y)R w7v
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 rows below
Existing Building❑ Repair Alteration O Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change u(Occupancy ❑ Other O Specify:
Am building plans and/or construction documents bring supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineeryy��++K Peer Review required�? / Yes ❑ No
Brief Description of Proposed Work: Lmo0 ' n)c '1— I l(Tl.{�
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): I Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: 1 Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Nu.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business O E: Educational O
F: Facto F-1 O F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-i❑ M: Mercantile❑ R:r Residential R-10 R-2 O R-3❑ R-4❑ j
S: Storage S-1 O S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IS 0 HA ❑ [ISO IIIA O HIS 0 IV ❑ 1 VA O 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:
:1 trench will not be Ltcen.ed Din)atsal Site❑
t rival Check duutsZorde e: Lone Indicate mumapal❑ rrqutred•9or trench r.I+cclf%mel�.f `✓id
I'ncatr❑ nr mdrnitiv Zone:_ or on ate sartrm❑ permit a endo.ed❑ :t-I o l bkV6
Railroad right-of Hazards Hazards to Air Navigation: \I:t I h-t.•n.(-.•mnn-v•n Rrv... Pn• c..:
\vt .\)q'hcablc Id✓ I.Structure,uthm evporl,tppm.tch arr.l' 1,their era tcw cum(•Idrd.'
. rl onvnl to Build vild",ed❑ Ne,❑ Nu(,V Ya•,❑ \u ❑
SECTIONS:CONTENT OF CERTIFICA IE OF OCCUPANCY
1 J.11nn.d('"de L a•l:roupt.e fa peot Gm.trucuon; Occupant l o.id per flo. r
IAx-�Ihr budduaq cntLun an}pnn6lrr>a.trm': �p•cial?hptdationv
SECTION 9: PROPERTY OWNER AUTHORIZATION
N:t a aria Address of Proper) v er � .2efi
Name(Print) Nu.and4reel City/Town Zip
lhcner Contact Information:
Title Telephame No•(busmess) Telephone No. (cell) e-mad address
If applicable,the properly owner hereby authorizes-
Name Street Address City/Town Slate Zip
to act tin the .ro perry owner behalf,m all matters relative to work authorized by this building permit a ++lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is lam'than 35.tM cu.it.of an.kwd space and/or not under Contnhlion Control than check hem O and skip Section IGLU
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Co n Name:
N.)me of P n Respot; le for Construction License lyo. and Type if Applicable j
Street Address City/Town S to
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM.G.L.c.15L 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
and Materials) Total Construction Cost(from Item 6)=S 3 S/2U b
l: Building $ S Z(f U Building Permit Fee=Total Construction Cost x_(Insert here
L32.Electrical S appropriate municipal factor)=5.I'lumbing b
4.Mechanical (HVAC) S Note:Minimum fee=5 (contact municipality)
5:Meeh,nical (Other) S
_ Enclose check payable to
i.Total Cost 5 2(f Z (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
BN enlenng my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
al. a t, e and -curate to the best of my knowledge and understanding.
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•' �1 J� rV1 fVIClJ�f,GGI lam!'-P✓7�-!� Cr/�334 Lo��� �
i ihd"gn .192V title !a•I hune\u. Date
?In�•1 .\chin.. Cih;'Toacn ale Zip
Municipal Inspector to fill out this section upon application approval:
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