0025 - 0027 BRIGGS ST - BPA-2011-696 The Commonwealth of Massachusetts
Department of Public Safety
klas.ichuwty,State Building Code(780 C NI R)Seventh Edition
City of Salem
t Building Permit Application for any Building other than a 1-or 2-Fa it
i (This Section For Official Use Only)
ya I
\� Budding Permit Number: Date Applied: r Budding Inspector:
L' � I SECTION 1:LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is n t available)
�c� NA
1 No.and Street Cite /Town Zip ctkie 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 a I Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
ChangeufUse ❑ Change of Occupancy O Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes Cif No ❑
Is an Independent Structural EngmeerinyyP er Review required? y�Yes ❑ No QQ
Brief Description of Proposed Wurk: IR(C►Z (1(/>7L�2L6K {Z�c'AkzV.tfiet./5 �,4lieft' r lGltz-emu
CA;4p3(Alyr"5 fc-t-e
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): 2 Proposed Use Group(s): R P
Existing Hazard Index 780 CMR 34: 2 Proposed Hazard index 780 CMR 34; 2
SECTION 4: BUILDING HEIGHT AND AREA
4Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.it.) s�T. _Total Area(sq.ft.)and Total Height(ft.) G4 'fir 9-v
SECTION 5-.USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-❑ A-5❑ 1 B. Business O E: Educational ❑
F: Facto F-1 ❑ F2❑ IH: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-10 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 ❑ Is IIA ❑ [ISO IIIA ❑ 11180 IV VA ❑ VBJO
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:
Public Check if uut,ide Fh%,d Zune)4 Indicate municipal X A trench will nut be 1-wen.ed Di.pus.l Site
rcywred Nor trench nr,peaa h';
f I'nratc❑ or indentic Zone;_ or on wte a•.tem ❑
permit i.enclosed ❑ �-XJCZ'bI$Fb5a.-
Railroad right-of-way: Hazards to Air Navigation: ,1A 1 h.h-n. (-.•nuui.-urn 14..„•.. Pr"""':
\+d .\F phiabtc s+C L Slruilure aulhm.nrport approach.trra' 1,thru era icte omirlelyd'
i M
r t nn�rnt in Budd rndi .rd ❑ 5 r"❑ ur Xi.W Ya•� ❑ \,+
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY -
I..hlom ,1 60,- �'RI_l,c l:n n+pi.1: it pr of i.un.truiuun: t)ccupant 1 o.id four hlnur
ILa.tha•buddu,,t•.,uttam an Spnnkk•r>a.trm': Spacial Stipulation. 7110
SECTION9: PROPERTY OWNER AUTHORIZATION
N.t((*��e and Addrt,t of Property C`%
I, I�otLorRdf( 41 FA4X 6Ujq,- of
Name(Print) No.and Street City/Town Zip
Proper v Darner Contact Information:
;rye — — -�
Title Telephone No. (business) Telephone No. (cell) e-mail address
lfaLIL+licable, the pr +rrt rner hereby authorizes
kr�tc �, sw( MA
Name Street Address City/Toavn State Zip
to act on the pro pert%oaener's behalf, m all matters relative to avurk authorized by this buildin + permit a p pl icat ion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It building is less thin 35,uU)cu.it.of a'n Io d s ace and/or not ureter Construction Control then check here O and skip Sntiun 10.0
/10�.1 Registered Professional Responsible for Construction Control
1/i��ICEL M. SYbisK� - S75-5-7 S Dr�ut r�ttsr�31[,I.htaM 2Do38
Name(Registrant Tele phone Nu. e-mail address Registration Number,
t2e(�r4+alf�s ��� �IlE�12LY o19t5 $ l r
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
��vc�e C�Ns-n�ffcnor�
Compan
L4"r'RZIGIL
Name of Person Responsible for Construction License No. and Type if Applicable
SAuSgu►ZY
Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMMNSAIION INSURANCE Amt)AVTr(M.G.L.e.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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=S gar ooe
1. Building S Gd 00 U Building Permit Fee=Total Construction Cost x,_(Insert here
2.Electrical S t p 00 0 appropriate municipal factor)=$
3. Plumbing S 10 0000
4. Mechanical (HVAC) S Note: Minimum fee=S (contact municipality)
5. Mechanical (Other) S Enchrse check payable to
6. Total Cost S �6 t QO0 (contact municipality)and write check number here
s SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enterri g my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicatton is true,md accurate to the best of my knowledge and understanding.
('leas print and .ign name Title Telephone Xo. Date
ntwef .Lddres Cttv;Tuan tit. e Zip
Municipal Inspectur to till out this section upon application approval:
\ame I a[e
90
J
�?F 6)
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT LOCATION: 25,27 Briggs Street, Salem,MA
PROJECT NAME: Renovations to 25,27 Briggs Street
NATURE OF PROJECT: Interior renovation
ARCHITECT: DMS design, llc
ADDRESS: 100 Cummings Center, Suite 424G,Beverly, MA 01915
TELEPHONE: 978-578-5748
In accordance with Section 110.0 and 116.0 of the Massachusetts State Building Code,I, Daniel M.
Skolski,Registration No. 20038,being a registered professional Architect,hereby certify that I have
prepared or directly supervised the preparation of all design plans, computations and specifications
concerning,ARCHITECTURAL Plans,for the above named project and that,to the best of my
knowledge, such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,all accepted engineering practices and applicable laws and
ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to determine
that the work is proceeding in accordance with the documents approved for the building permit and shall
be responsible for the following as specified in Section 116.2.
Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit, and approval for conformance to the design
concept.
Review and approval of the quality control procedures for all code required controlled materials.
Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix G.
Pursuant to Section 116.2.2,I shall submit periodically,_daily,_X_weekly,or _other periods
(specify)Weekly progress reports together with pertinent comments to the City of Salem Building
Department.
Upon completiop of the work,Architect, shall submit final affidavits as to the satisfactory completion and
readiness of the roj ect for occupancy.
Signature
Then personally appeared the above named game rI and made oath that the above
statement by him is true.
Before
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r .