14 BROWN ST - BPA-11-290 r 1
of The Commonwealth of Massachusetts
Department of Public Safety
\Iassachu.ett,Stele Building Code(780 0IR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwelling
(This Section For Official U.,e Only)
Building Permit Number: Date Applied: Building Inspector. btzrrq
SECTION 1: LOCATION (Please indicate Block S and Lot M for locations for which a street address is not available)
.No. and Street City /Town Zip Code 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❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changeof Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineerin ,Peer Review required? 1 Yes ❑ No ❑
Brief Description of Proposed Work: + Cmd �.
LcJ COM.vG�t�
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): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
r Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Cheek as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑7 B: Business 2r E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
I: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile ❑ R: Residential R-I❑ 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 ❑ 1B ❑ HA ❑ JIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Perrnit: Debris Removal:
Public❑ C heck if outside Flood Zone ❑ Indicate municipal ❑ A trench will not be Licensed Di,posal Site❑
required ❑or trench or ,pcafr:
I ]mate ❑ or indenlik Zone: or on site sv,tem ❑ permit d enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \In I li,ton.Cnnnu,�iun Ito,I,„ I'ri err..;
\ot auble ❑ 1,StrUC[tnc,r I lh III airport appmoch area' I, their recicw cnmplcted.'
,,t (-Dui<en1 In Build end,„ed ❑ 1'e,❑ or.\'n❑ Ye,❑ \o ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
lidnion ill Code'. _ U,c Gruupl-): f%pe of Cumlruclwn: OCCLIpanl Load per 19oor .
1)nv. the buddilIg cnntain an Sprinkler S.%,tem.': Special Stipulations
S
SECTION 9: PROPERTY OWNER AUTHORIZATION 'r
Na "Ind" I e.. f 1 ,perly Ow /
Name(Print) No. and Street City/Town Zip
�,.,��per t)wner Contact Inloormatiun:
4 C)WA A. r NF✓Uanz .t1Rfi
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name I Street Address City/Town Stale Zip
to act on the pro pert%owner's behalf, in all matters relative to work authorized by this buildin •12ermit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,W0 Cu. it.of endued s pace and/or not under Construction Control then check here 0andskip Section 10.0
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
mpany Nam 0. . 9 s f
C S l
NC mE of,P� ,,o rp�nsi,bIF for Construction Ljknse No. and Type if Applicable,
Street Address r T 4C 7 odY6 City/ToNpu�H� (�Sla
,e 6CJ� y1 pV1 `)'C11 C
GcoJa•5 ttil
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION WSURANCE AFFIDAVIT(M.G.L.c. 152. 25C(fr)1
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
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 $�p2,p2�(, •�' (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereb st under the pains and penalties of perjury that all of the information contained in this
application is true and accurate the bes of my wledge and understanding.,Dart
«( �2atXvv o �l tiGJP� 7rYl_ 63a oZ3 o�—
I'Ic 1.e print it *igt name Title cl k_ ).1
ate
� ►�g.e ♦,�ot,o,.� C�c an�sba�,;well Addreas City/Tool ti eMunicipal Inspector to fill out this section upon application approval: 0
e
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