51 BRITTANIA CIR - BPA-11-443 l The Commonwealth of Massachusetts
Department of Public Safety
\Ie..,rchu�etL.St.ue Bwldirig Code 1•-80 C\IR)5rcen l h E.Luun !
�- City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(rhis 1e twn For Official Use Oniv)
1
tiwidong permit .Number: Date Applied: '7 g`//e1U ZD[n Building Inspector:
S//E��CTIO�NI I: LOCATION IPeease indicate Blocks and Lots for locations for which a street address is not available)
O/S70
.Na. and Street Citc /ioavn Zip Code Name of Building (it.:pl+bcabla)
SECTION 2: PROPOSED WORK
It New Construction check here❑or check all that appl y in the two rows below
Existing Building- Repair❑ 1 Alteration riAddition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changeuf Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur curisinrction documents being supplied as part of this permit applicatiun? Yes ❑ No @?�
Is an Independent Structural Engineering Peer Revirw required? Yes ❑ No 7W
Brief Description of Proposed Work: Lam- opftei
Is
L ?�
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 780CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
N
o. iuurs/Stories(include basement levels)&Area Per Floor(sq. ft.)
ea(.sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
mbly A-1 ❑ A-2r ❑ A-2nc Cl A-3 ❑ A4❑ A-5 O B: Business ❑ E: Educational ❑
F-1 ❑ F2❑ H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
tional I-1 ❑ 1-2 ❑ I.3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 O R-3❑ R-4 ❑
ge S-1 ❑ }2 ❑ U: Utility❑ Special Use❑and lease describe below:
'.se:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
CIB ❑ IIA Cl lie ❑ IIIA ❑ IHB ❑ IV Cl VA ❑ VS Cl
SECTION 7: SITE INFORMATION (refer to 760 CMR 111.0 far details on each itern)
i Water Supply: Flood Zone Information: Sewage Disposal:
French Permit: Debris Removal:
I'ubbi❑ ChcCIA Ituubida•IIn, J Zone❑ Inabc.ue mu mnpal ❑ A trench wdl nut I,e 1_i:cmcd Ornpu...; ?ila
v reaµnred ❑or trench -c I•ca lc.,ry--
I'ricate❑ r udcn lilt Zuna•; ur un.ale•%,Iem ❑ f,ermn i,enclu.nd O
I Railruid right-of-way: Hazards to Air.Navigation: \I \ I hd••n, i . ....... ,i IL, t 15
\rl \pplia.ddr❑ Lslrucluic uilhm.iirI.N.rl.ippn .iih.rrr.i' Lihco n•a ica. nanl•I.IrJ
•a l',.•i.r,I t,. Budd cnJ, -cal ❑ I Nv,13 .-r \o D 't" 0 Cl
SECrio.N 8:CON"rE.NT OF CERTIFIC,\fE OF OCCUPANCY
I .hlun d 1 ,•.Ic _— l-c ln u)v-i _. fa I`c I 1 .ni-Ini.li,m. ____ iiciiil•.urt 1 ••d.l F,r II ,. __.___.. _._
Ii. r. Ihr l•inLbnq., nl.un.m sl•nnAloi �a�qm` `F'rcial�u)¢iali�n. __ ___ __ �
SECTION9: PROPERTY OWNER AUTHORIZA riON r
\' ne.ui I r\.Idn•r� 11' + L+crty Uwnrr
\.i ntr lPnntl' N'u. .uaa1 }In•rl Cth ; Town rS F+ 1
1'rul+erl% Ua,ner Contact Inlurmom,ri r
6c�dw c�lZ '97g. 75'- SSS'7 PO
Title relephone No. (bunmr>n) Telephone No. (well) e rn.ul .tdJ re.�
If epphc.ible, the pnrpvrty oc,ner here1w.nnhurtces
Name Street Address City/Town State Zip
I,+act can the ro •a•rfy car%ner'.behalf, m.ell matters relative to work authunted by tht:building +rrmrt.t + +hc.nn nr.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(it 1•ud,bn•is I,.s than 1;,UlU cu. tt cat endued:rare and/car nut under Co.n>tmc can Gn I then check here O and.kt +S.•.bun to 1)
10.1 Registered Professional Responsible for Construction Control
EeGS1��erM¢2�DlS2� ZA--- 812?3a57c7 e€�»° cQ6el� ofms��,c /SJ�(o�/7
Name(Rrgistrar�U reiephuf a No. a-mall address Registration Numb�� /
�//95ti .car Ll2 A Rezg:-.J•rs� O"g- � 20/2
Street Address City/Town ;fate Lip Discipline Expiration Date
0.2 General Contractor }�
L 5 �l�wx e Q �PA,`J2 f w p bAV, e L �? �RA,,IC ee—
ump any Name: n/� c ['1 �J�• /—
I- e-L- , !S/9ry{ e L C$ 7�0 / J
N r�S r�Rr r blr rr2C-unstructiun y a 2 Lic nse Nqr and Type if Applicable
,G U��•X� OI�G
Viatr t Address City/Town ��/ t Zi
- ? ���57 �^ 7 _ os�C) r�ei,bA,r/�PL �elrvv)kL cat
Tele hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS' O NSA I N INSURANCE AFFIDAV (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 issss+ante of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _§
1. Building $ �/' Z Building Permit Fee= Total Construction Cost x / •L�
_(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 § P•y
(contact munici alit ),and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entenng my name belnw, I herebv attest under the pains and penalties,of perjury that all of the infnrmatiun nint.uned in this
r)plicatmn is true.md arnirate to th bent nf.my knawlcd •rand understanding.
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Municipal Inspector to fill out this section upon application approval:
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