80 BOSTON ST - BPA-11-267 DEMO GARAGE r � —
;. The Commonwealth of Massachusetts
Department of Public Safety
.\la..sachusvu.,State Budding;Code(780 C:\IR)Seventh Edition
1 City of Salem
` Building Permit Application for any Building other than a I-or 2-Famil Dweilin
IThis Section For Official Use Only)
(/1 Building Permit Numbrr: 0.ne Applied: Building Inspector:
''Jmf SECTION 1: LOCATION (Please indicate Block M and Lot 0 for locations for which is street address is not available)
No. and Street Cite' /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 13 1 Alteration ❑ Addition❑ Demulitio lease fill out and submit Appendix 1)
Changeof Use ❑ Changeof Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No a' _
Is an Independent Structural Engineering Peer Review re.wired? Yes ❑ No (l
Brief Description of Pru osed Wurk: lS s' d1 F,
�fl'v C r a fit S
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): r
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 S:USE GROUP(Check as ap licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc O A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 O I H: High Hazard H-1 ❑ H-2❑ H-3 Cl H-4❑ H-5❑
L• Institutionaf I-1 ❑ 1-2 ❑ 1-3❑ 14❑ M: Mercantile Cl R: Residential R610 R-2❑ R-3❑ R-4❑
S: Storage S-1 O S-2 ❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 11 LO for details on each item)
Water Supply: I Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
rLJ ❑ Chuck d uuto-tde 19uud Zone❑ Indicate munwi of❑ A trench will not be Liccn.eci Di.puwtl Site❑
required Our trench ur ,cafe:
I'ricaly❑ sir indenlifc Zone: or on�i to>%,,tem ❑ i
permit t.vnelo.ed ❑ _
I(ailroad right-of-way: Hazards to Air.Navigation:
\,rt .\pphc.d lc ❑ I.Nru.;urc„nhm aupurt appruaih area' I.thew n•a ic,c cumpl,w,r
r l- m.rnt pi Hudd cnd,i.cd ❑ lr.1J nr Nil I 1'e.❑ \o ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
(\pent(-,)jr.lructtun: ticcupant t(,.i f,cr l-I,nur
1)-c. thy buildn,g;. n4un.tn Cpnnklyr tit.lrm'� �f,a•cial?upulahnn. ----
SECTION 9: PROPERTY OWNER AUTHORIZATION
AF(Print)
of Pruperiv Owner
Nmand Street Cite/Tow'nZ2)
Lip
tact Information:
Telephone No.Ibusin �%) Telephone No. (cell) dress
If.applicable,the property owner hereby authorizes
Name Street Address City/Town
to act on the +ro+rrtc oevnrr's behalf, m all matters n•latier to avurk authorized by this buildin on.SECTION 10:CONSTRUCTION CONTROL(Please fill out Appe(It buildin•is less than 3i,oMcti.ti.of enclosed. an•and/or not underConaruitiun Control then ch +5ev lion I0.11
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
Gk?JEf_GteJooD c- SCA- 5 TNe
o
CC p y ame:
AW3 Glfr-1ffAJ sooD !a & b 6 FxP 7%a y�i�
Name of Peres Res msible for Construction License No. and Type if A plicable
_i !(r/f5!N1�id7 z INEXIP40SE 0,212G
Street Address City/Town State Zi
78L1�G.s� By� 2Z-� ada GrPr5Avwuk7AA; v.5Bre-LdERTZovaET
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WO ERS' MP ATION 5 RANCEA DAVIT(M.G L.c. 152.§ 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# No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item EQedsts
Total Construction Cost(from Item 6)=S1. Building $ Building Permit Fee=Total Construction Cost x
(Insert here2. Electrical sappropriate municipal factor) S3. Plumbing s
4.Mechanical (HVAQ SNote:Minimum fee=S (contact municipality)
5. Endow check payable to
6.Total Cost scon'7 munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I herebv attest under the pains and pen.iltiea of perjury that all of the information a.ntained in this
applica hun is trier anet accurate ha the best of "y know e � d understanding.
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Municipal Inspector to fill out this section upon application approval:
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