297-299 BRIDGE ST - BUILDING PERMIT APP f
The Commonwealth of Massachusetts
Department of Public Safety
'y'y y \lusarhusell.State Budding Code 1780 CMR)Seventh Edition
City of Salem
Building Permit A22lication for any Building other than a I-or 2-Family Dwelling
(This Section For Official Use Only)
Budding permit Number: Date Applied: Building Inspector:
JSECTION I: LOCATION (Please indicate Block N and Lot 0 for locations for which a street address is not available)
niiJI 297.299 P,x4o&6 St d1.eM f MA 0197� �,wa -1'yaSAI- S7-oE2
1� Xo. and Street Cite /Tomvn Zidm Code Name of Building(itopplicable)
SECTION 2: PROPOSED WORK
If New Con,arLIChUn check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition ❑ Demolition 0 (Please fill out and submit Appendix 1)
Change of Use Cl Change of Ckcupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No W
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ffir
Brief Description of Proposed Work CAIb LF J3 GLE19i✓ �'
"LLAA1 7Vu d EA
TN F p.PbP�,2
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($):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 'L 2 N V� r
Total Area (sq. ft.)and Total Height(ft.) 9 V N�sr
SECTION 5:USE GROUP(Check as applicable)
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 I-1 ❑ 1-2 ❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ IIB ❑ IIIA ❑ I118 ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
I Trench Permit: Ueb ris Removal:
Water Supply: Flood Zone Information: Sewage Disposal:
PP Y _ :\ trench m,ill not be Licemed Ui.pu.al Site.f�
Public ❑ C heck d oul.ide I lu,,d Lune❑ Indicate municipal❑
required eor trench .rr'peclk:
I'Icah.❑ or umJen oft' Znne:_. JI�O ite>c.tem ❑ permit tl enclu.ed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ f Inb n. t-..�nmi..um H.. . I'r •o•.:
\.a \f•phcd•Ic J I L�tru:nirc..ilhui .tu')� rt el+pn�.iih area' Llhcir rt•.ic.r rnn(dclrrC
.n'l '•n.rnt I" Build rnd..wd ❑ lr.❑ �-r Nk, }'r. ❑ A, �
i
SECTION 8: CONTENT OF CERTIFICA It OF OCCUPANCY
I..idi n a l dr -.!_ L'•r l rvfn-c _. 1%PL'Ol Occufp.tnt [,,ad pvr if,.or
. I)„r. Ihr l`uildna numt•ve.ln tipnn6lur}m.irm`. ,}5[ `)'ocial?lipula Uunv
SECTION 9: PROPERTY OWNER AUTHORIZATION
erNaeandAddressrf Pn�perty Owner OWNE/Z NDT ✓
nStreet
m (Print) No.ad Cite/Town Zip
Propvrly lhvner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If.tpplicable,the proper(.' owner herebv authorizes
Name Street Address City/Town Sta to Zip
to act on the 11r, pert% m ne(<behalf, in all matters rclatice to work.w thonzed by this build in6 j,erm rt a ppl Ica l ion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(II building is less than 35,W0 cu. It tit onafavd s,ace and/or not under Con.+truction Cootrol then check here 0 and skit Section It)1)
10.1 Registered Professional
Responsiblesf�or-. ru
41 Constction Control/�
, V7,-,G1yZ 0•G GTiC';0 Z o SS/9 Welh/7fd,-/ea1 (are1,15. e±nw o %Z�i7
e(Registrant) Trl_rp/hone Nu. a-mail address Re istration Number_ /
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
e'-'& )9,pfjORs Erg/V/koN/1��AL Sc'RV/G�S� /NC.
Company Name:
ScefN =Z�r1WI/✓
Name of Person Reslxmsible fur C nstruction Ueense No. and Type if A livable
L o�✓r�wATE.2 1�.e/✓� lV�2w�e� i 0 2 o to
Street Address City/Town St to Zip
?BL-291- 5"V 712L-�- 07Z 6 )rwI —1coclea�l�)a"k ;5 , coM
Telephone No.(business) Telephone No.(cell) email address
SECTION 11:WORKERS'COWENSATION 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 si ned Affidavit submitted with this application? Yee Pf No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor WA1Y f9
g
tem and Materials) Total Construction Cost(from Item 6)=$
$ Building Permit Fee=Total Construction Cost x_(Insert here
l $ appropriate municipal factor)=S
g $ - _
cal (HVAC) S Note: Minimum fee=8 (contact municipality)
ical (Other) S Enclose check payable to r'
st (contact munici alit )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 t.s true and accurate to he •sI n f�owledge and undervtanding.
n t�N Sxw��✓ d 1490 o r3c T d'�G2 7-FL
I'le.r.r print and apn nai r Fide Telephone \n. Do c
_f�,t 'GoNGWAT�/Z- �1Z. /Yd2WELL-- �� 0 206)
titrret lrirlrc�. (own }fate zip
municipal lospector to fill out this section upon application approval:
Vame Date
1