97 BOSTON ST - BPA-2010-536 ADD KITCHENETTE The Commonwealth of Massachusetts
Department of Public Safety
Nlassachu.clts State Building Code 1780 CMR)Sex -nth Edition
City of Salem
Building Permit Application for any Buildin other th in a - m' Dwellin
(This Section For Offic.ml Use Only)
Building Permit Number: Date Applied: Building Ins m m
SECTION 1: LOCATION (Please indicate Block M and Lot M or locations for which tr address is not available)
97 Ros�o� sT Slh'Qrizi
:No. and Street City /Town Zip C.de Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Buildings Repair❑ Alteration )�. Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 1I No ❑
Is an Independent Structural Engineering Peer Review required? - Yes ❑ No
Brief Description of Proposed Work: TN�fi/ %�C�'1P,b/(�/%�
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 Use Group(s): Proposed Use Groups$
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 6MR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area (sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check ae ap livable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard - H=1 ❑ H-2❑ H-3 H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ 1-4❑ 1 M: Mercantile❑ '"`Ri'R'esid'eritial+ R-10 R-2❑ R-3❑ R-4 ❑
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 ❑ fill ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ V
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 if....side Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
Private❑ .r Indenti % Z.ne: or site scstem ❑ required ❑or trench or.pecifv:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I li>nmir c�,,mmurLm Bede:%
.N'.t :lpplicablo❑ do Slniiturc wuhin airp.r[approach area.' Is their rrcien'njE03"
tad'
11r CM11 nt 1. Build end..ed ❑ ~ Yes❑ or No❑ Yes❑ NSECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
TcpeufConstruction: Ocaipant Load per Ilu.
D::vslhc•b�ildin�;conlain,(n Sprinkler timslc•m?; Spec Stipulations!
SECTION 9: PROPERTY OWNER AUTHORIZATION
Mime and Address of Properly Owner
SiP did �• i'.fii;dr
Name(Print) Nu.and Street City/Town Zip
Properly 01%ner C6ritact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, th pro perty owner hereby_,authorizes
Name Street Address Citv/Twvn Slate Zip
to act on the poi pert%owners behalf, mail matters relative to work authorized by this building permitapplication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if buildin•is less than 350)0 cue ft of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
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
WA Ar6tir
Cum in Name.- G� CS Dr�f=oyi 0
Nam of Person Res onsible for Construction License No. and Type if Applicable
Street
cStree Address City/'Down nn�G,NN Stat Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
�b-A ��h V-40:c--41�
Pleaxc print and aign name Title - Telephone No. Dale
(&yl /Z_ 6� ��iOepmy /yid D q ey
titreel :\ddress Cit%:Town S e Zip f1
.Municipal Inspector to fill out this section upon application approval: - �1. �v
NW 1
Date/
Sterling and Selesnick
97 Boston St.
Salem, MA
6-1-
7 O -
O
proposed kitchenette
M Existing bathroom