144 CANAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
1, Department of Public Safety
'� �`.....✓ \hus,tchusell.State Budding Code 1780 C\IR)Srernth Edition
City of Salem
Building Permit Application for any Building other than a I. or 2-Family Dwelling
1 rhis Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION IPlease indicate Block 0 and Lot 0 for locations for which a street address is not available)
No.and Street Cih• /Town ZipQkle Name of Building(if opplicable)
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 ❑ Change ofOccupancy ❑ Other Specify: _I>C-wo -�--;jb& G/G9r..o
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 3
Is an Independent Structural Engineering Peer Review required? f Yes ❑ No 8,
Brief Description of Proposed Work: "J-rtsSt �iC�(Lxlc
Cfcaa-r-d - n�-1^
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): r
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 ❑ A4❑ A-5 O I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 O H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 14❑ 1 M: Mercantile❑ It. Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-I ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION b:CONSTRUCTION TYPE(Check as Applicable)
IA ❑ ISO IIA ❑ IIB ❑ II►A ❑ IIIB ❑ I IV O 1 VA Cl VB ❑
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 i(outside(loud Zone❑ Indiarte municipal ❑ A trench will not Lie Licensed Disposal Site
ite OL
.
I'rrrale❑ or mdenti(v Zunr: or tin site sv,trm❑ required hor trench o permit is enclosed ❑ r pecily: COV�/K
Railroad right-of-way; Hazards to Air Navigation: \1\ I I(........ 1'ma
\id :\pphcible� I,Strucltoe within aupurt approach area.' Is their revive%cumplvied,
•n'lm,cnl to 1$111d enclosed ❑ Ye,❑ or NA - Yes❑ \o ❑
SECTIONS:CONTENT OF CERTIFICA rE OF OCCUPANCY
I:.InwnulCodc r:peu(Con.. lrui uun: Occupant Lu.td per Iluar:
1)oc,the budding cnnt.un,in Sprinkler Sc,tcm'' Special Stipulations:
7 �
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namv and Address of Property Owner
Name(Print) No.and Street City/Town Lip
Property 0%%ner Contact Inlurmation:
A,!6L, 0- - 7 9 - 4tRV5,
Title Telephone No. tbusiness) Telephone No. (cell) e-mail address
If applicable, the uuperiv.uwner hereby authorizes / f
5/1/i4466ii s GST b'CfZwwrtA a /a9ff7
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin• permit a >,lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(it buildin•is less than 35.t W cu.It.of enclusW s ace and/or not under Construction Control then check here O and skip Section I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrm41 T yqe No a-mail addres9 O f�� Registration Numb / 01
0
'17
Street Address City/Town .State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing $
4. Mechanical (HVAC) S Note:Minimum fee=f (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6.Total Cost 5 �>1600— (contact municipal i t )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
Application is true and accurate to the best of my knowledge d understanding.
�'2
('lease print,md sign name rifle Telephone.No. Date ,.
_ Cl bl 7Zc TA GXLI W O/&2/—/F/Z
Ilvvt :Address City/Toren ate Lip �
Municipal Inspector to fill out this section upon application approval: u 0
..\ameI J. I),u