136 CANAL ST - BUILDING PERMIT APP p The Commonwealth of Massachusetts
vtµ Board of Building Regulations and Standards Town of
1 ky Massachusetts State Building Code, 780 CMR, 71h edition Building peps
Q Fiuilding termit Application anstruct, Repair, Renovate Or Demolish a > tl011
1 _1 O te- or Tno-F nily Duelling
This iSe tionfokOfflcial Use Only
Building Permit Nu m er. YLXDateApplied:
Signature:
Building Commissio er/lnsPcfJbr,,b4uildings Date
CTION 1:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
i 36; C a,4a I s r salt
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fT) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided ..
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood_Zone Information: 1.8 Sewage Disposal System:
Public 9k Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal 56 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: / /-,t
/ �f�r--��/�T I
lName(Print) ? Address for Service:
Si nature - - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building%j Owner-Occupied ❑ Repan�OSpe
tion(s) ❑ Addition ❑
[2Elcctrical
molition ❑ Accessory Bldg. ❑ Number of Units_ Ot
ef Description of Proposed Work':
F XF^ U/l^(7 FWZ7l B'•'t O� iaC.l S'"j
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Labor and Materials Off7cial Use Only
uilding $_ C��C7QG1 U� 1. Building Permit Fee: $ Indicate how fee is determined:
g p ❑Standard City/Town Application Fee
�7 S..S O, UO ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ L9 a'-DL) , 00 2. Other Fees: $
4. Mechanical (HVAC) $ /fo[Lr)e) OU List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ',�Qs�+ oQ ❑ Paid in Full ❑Outstanding Balance Due:
�2
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 4✓,�b /, i_bs_ -zOit • -
.,P6fiZr' \/ License Number Expiration Date
0.tOrle
NRmc of CSL- Holder V List CSL Type(see below)
ril. S" bAr1 Cr3 Type Dc_criouovy
Addres U Unrestricted(up to 35,000 Cu.
��L, - ft Restricted 1&2 Family Dwelling
Signature M Masonry Only
i 0 3 RC Residential RoofingCoverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istered Home Improvement Contractor(HIC) /2 7*J !
�e fp—r i/-ti L e d e Registration Number
HIC Corn my Name or HIC Registrant Name
7 iF 4orl h ST D i3i4yr r.f /Nii -/ y .- y U 0 9
Address Ex Expiration Date
ems, lUau� I?8/953-7>aV p
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR.CONTRACTOR APPLIES FOR BUILDING PERMIT
I,X/ .� as Owner of the subject property hereby
authorize tsl'C r VvLr e to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
t t the statements and information on t e foregoing application are true and accurate,to the best of my knowledge and
behalf. t ` �
G V� r Ar6a
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of r u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) Z 3O0 (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count Z
Number of fireplaces Number of bedrooms
Number of bathrooms Z Number of half/baths 'L
Type of heating system /- t7i Ai R v Number of decks/porches
Type of cooling system Jh ii AL Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
eke a, � CONSTRUCTION CONTROL AFFIDAVIT
Project Location: 138 Canal Street,Salem MA
Name of Building: Retail Building
Scope of Project: Renovate existing single floor retail building
In accordance with Section 116.0 of the Massachusetts State Building Code,780 CMR Seventh Edition:
I,Daniel F.DiLullo,Massachusetts Registration Number.6033 being a registered Architect hereby certify that I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerning:
Entire Project:_ Architectural X Structural__ Mechanical
Fire Protection_ Electrical_ Other(specify)
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 acceptable
engineering practices and all applicable laws for the proposed project.
Furthermore,I understand and agree 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 by the Building Permit and shall be responsible for the
following as-specifiedin Section 116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction documents as
submitted for the Building Permit and approval for the conformance to the design concept.
2. Review and approve of quality control procedures for all code-required controlled materials
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of
the work and to determine in general if the work is being performed in a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, progress reports together with
pertinent comments.Upon completion of the work I shall submit to the building official a final report and
Affidavit as to the satisfactory completion and adiness of the project for occupancy.
Signature of Registered Professional: G�
Subscribed and sworn before me this o2 day of)4 »bA 2008
Notary Pub SUSQ►) 4 t!10 My commission expires on ')1/01 aa16