42 BUFFUM ST - B-10-310 a
The Commonwealth of Massachusetts
. _� Department of Public Safety
1 !J•
�� -rr-„✓ .Ai.issachusett,State Building Code(780 CMR)Seventh Edition
j City of Salem
r J Building Permit Application for any Building other than a 1-or 2-Family Dwellin
v (This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
q2 0lg70 —.�3 73
No.and Street City /Town Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
n If New Construction check here❑ or check all that apply in the two rows below
y Existing Building ❑ Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) `
'\ Change of Use ❑ Change of Occupancy 0 city: �bp,n -U�.
Are building plans and/or construction documents being Supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: _ Jn S zfn �%K fi y 7 d'� ✓voa d s foee
aAd e-Ai, 02e!. p:pr>
X
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): 8
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.)
Total Area (sq. ft.)and Total Height(ft.)
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: High Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R- R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility ❑ 1 Special Use ❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Su I Flood Zone lnfomration: Sewage Disposal: Trench Permit: Removal:
PP Y�
Public ❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be F—Defris
ensDisposal Site❑
required ❑or trench specify:
III i ca to ❑ or indenlily Zone: or on site system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I oo io.c Pnrrs.:
\ut Applicable❑ Is Structure within airport approach area? I. their rec ie%c completed.'
or C nnsent to Build enclosed ❑ Yes ❑ or.No❑ Yes ❑ .No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Tc pe of Construction: Occupant Load per Floor:
Dees the building contain an Sprinkler System?: \ Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Lip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the pro perty owner erebv authorizes �t /�
—�_
�nrltk� // /lft��� �(Z B /—, ",.S 5- � sa /t'.n AA 0/97y-a3 -73
Name Street Address City/Town State Lip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin , permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10,1)
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
L/\en t5- Ca/'{� P�
r` Cumggmy Name: . C S YQ ? S 9
Ktnne !�Ie/«,rz
Name of Person Responsible fur Constn ctbn License No. and Type if Applicable
5/� !YN��. h t Sa �rsst yli� IWX 0/v7C) -2? 7.�
Street Address City/Town State Zip
9,76--57ff S/� 97b% S7k- /eyz�pwp Y'aarA(Y j24/m,���
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 issuance 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 $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ t nicipaty)
5. Mechanical (Other) $ L
Enclose check payable to
6.Total Cost Lis (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest Linder the pains and penalties of perjury that all of the information contained in th s
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telepht ne.No. a e
titrect :\ddre.S Citc/Town State Zil
Municipal Inspector to fill out this section upon application approval: 1 I, o
te
Name Da