148 BOSTON ST - BPA-2010-949 DECKS �. The Commonwealth of Massachusetts
Department of Public Safety
�� i` \lass.tchusa•tts State Building Code 1780 C:\IR)Seventh Edition
City of Salem
Building Permit Application for any BuildinX other than a I. or 2-Family Dwellin
(this Section For Official Use Only)
Budding Permit Number: Date Applied: Building Inspector:
SECTION l: LOCATION(Please indicate Block a and Lot a for locations for which a street address is not available)
S -
No. and Strad Citc /Town Zip C,x1e Name of Budding(if applicable)
SECTION 2:PROPOSED WORK
If New Constructiun check here❑or check all that appty in the two ruws below
Existing Building❑ Repair❑ Alteratiun ❑ 1 Addition Cl 1 Demolition ❑ (Pleasr fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents bring supplied as part of this permit application? Yes ❑ No
Nan Independent Structural Enginrrrin Peer Rrvirw rryuir T �n 1 Yes ❑ No
Brief Description of Proposed Work: KQ,-n!'•il4 Q
J
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 Group(s)-
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 St USE CROUP(Check as a Iicable)
A: AssemblyA-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: HI Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ I-2 O 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S•10 S-2 ❑ U: Utility❑ Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a Ica ell
IA IB ❑ IIA ❑ 118 ❑ IIIA ❑ - 1118 ❑ IV VAjbn
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Dl:
I`ubhc❑ C•heck d outside FLn.d G.ne O Indicate municipal ❑ A trench will not be Lrcensite ❑
required Cl or trench ur.pa
I'nvate❑ Of tndrnoh� Lune: ur un.rtr sc.trm ❑ I+remit rs enclu.ral ❑
Railroad right-of-way: Hazards to Air..Navigation: \L\ I Intern l ••nun n•n n :(s their rva tc+c cnv.❑ or Nu❑ 1'es❑TION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I .hu.-n -d C.-Je_ Cv l�rnup,,v r+rvnt C�.nntntctn.n: Occupant Load Fvr l I....
I h.r. the Nrtidmg nn Special sortilattunsr
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
.V.i ranJ .\.Idrrss of 11roperiv Owner ( {{
�c/%n I�2 VS"& o Vn c t • e wA
Name(Print) No.and Street cito Town Zip
I'nq.w•rts' yore l imlactlnter
Title Telephone No. (business) relephunr No. (cell) a-mad address
If applicable, Ihv pruprrn• owner hereby authorizes (� I
C.As23oc SAr� -1-uS �S7 WctS �,"rie/� 4 S4 •
Name Start Addnms , City/Town Stale Zip
to act un the 1ni vrh'im nvr's behalf, ,n ail matters relam a h, work authorized by this tits ldin permit a p thcation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If bwldin is Ics Ihan 3S,uuU:u.It.of enc•kis.J s ace and/ur nut under Gun tructiun Con WI then chests hen O and%lu Sseuun 111.1)
10.1 Registered Professional Responsible for Construction Control
CAe-'aS a-72-467- 0033
Name(Rrgistnnt) II Trlephunqq Nu. e-mail address Registration Number
�S I InIaCI�I'c� nS1 ceJ2lAtiQ _�13SG CSC- /A
Street Address City/Town State Zip Discipline- Explratiun Da to
10.2 General Contractor
s co-
Cu any Inwane: ar. --I 3• L
c Son1tOS
Name of Person Respimsigle for Cu simctiun - L' en No. and Type if Applicable
/S '7UhC�1'a1�T ,, ST , �12aV n� O&W
Street Address City/Town State Zip
0J.J_-U07- Q02,3
Telr hone No.(business) Telephone No. cell e-mail address
SEC710N II:WO V (M.G.L c. 182. 23C(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
SEC770N 18 CONSTRUCTION COSTS AND PERMIT FEE
Item - Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)-f
1. Building f O B '1 g Pe. it Fee m Total Construction Cost x_(Insert here
2. Electrical f �— ppropriate municipal factor)e f
3. Plumbing f
3. Mechanical (HVAC) f ote: Minimum fee-S (contact municipality)
5. Mechanical (Other) f Enclose check _payable to
6. Total Cost f lI 300 (contact munici��alil )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby altea under the pains and penalties of perjury that ail of the information o,nhunacl in this
Application is true andl accurale to the bra of my knowleaige and understanding.
0033 Lo /'
Please print and .sgn name elute roephone.\o. Uale
_ /5-:1 Was � ,1 »; 0/ 93 44
�Irecl .Wdre•n Cit.%i Town `t.l to Zip
Municipal Inspector to fill out this section upon application approval:
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