48 CENTRAL ST - BPA I
t t 1 _X
;► The Commonwealth of Massachusetts
\' I Department of Public Safety
State Building lade(.780 C\IR)Seventh Edition
City of Salem
Building Permit Application for Any Building other than a I. or 2-Family Dwel t
(rhis Section For Official Use Only)
Building Permit Number: Rite Applied: " o^ Building Inspector:
SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not availlibisol
C �A� i /4/,4 O L 7® S 19 A Kt�
No.and Street City /Town Zip Code Name of Building(d applicable)
SECTION 2: PROPOSED WORK
It New Construction check here O or check all that apply in the two rows below
Existing Building I Repair O I Alteration Addition O 1 Demolition O (Please fill out and submit Appendix 1)
ChangeufUse O 1 Changeof Occupancy O Other O Specify:
Arr building plan- andl.r construction documeOts being Supplied as part of this permit application? Yes No ❑
Is an Independent Structural Enginverin err R,.efview,�^7 Ir ? �i T� Yeses O No
JIY—
ised Work:-V �d'l!\ j)
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) O
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 Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 3:USE GROUP(Check s a lfeable)
A: Assembl A-1 O A-2r O A-2nc O A-3 O A4 O A-5 O a B: Business O E: Educational 0
F: Factory F-1 O F2 O H: HI Hazard H-1 O H-2 O H-3 ❑ H-4❑ H-5 0
1: Institutional 1-1 0 1-2 O 1-3 0 1-4 O,1Me Mereantile R: Residential R-1(3 R-2)k R-3 O R-4 C3
S: Storage 5.1 D S-2 ❑ U: Utility O Special Use O and please describe below:
S Fecial U.se: �'...`
SECTION 6:CONSTRUCTION TYPE(Check as a licabls)
IA O too IIA O Ile O IIIA O 11180 IV 13 1 VA O V8 1]
SECTION 7:SITE INFORMATION (refer to 7SO CMR 111.0 for details on each item)
Water Supply: Flood Zone Inforrnatlon: Sewage Disposal: Trench Permit: Debris Removal:
I'ubhc O C hank it uubide PL...d Luna•O Indicate mumcrp,il O A trench will not be Licenvd Di,po it Site O
required O ur trench nr .paadc:
Private❑ ur indenuh. Lune: ur un.Ile sc.tem 0 ).remit i.ena•lu.ad ❑
Railroad right-of-way: Hazards to Air Navigation: xL\ I li-h.n, It.....n for.,.r••:
\.-I \pphc.&IL-❑ L�trunun•wnhut.nrpurt apF•n eacherea' h their rev lets oonplcled.+
r l• nt�cnl he Build cnd,.vd C3 Yc•O or.\n❑ Ya•+O \.+ Cl
SECTION B:CONTENT OF CERTIFICA rE OF OCCUPANCY
I ,fiu.m 1 11Jr. L�a•l�r.mpl•i. rtpv..l ticcupant Load pvr l4, r
Ihv. lhv!•ud.hnl;autlam en�pnnAlcr>\.Icm'' �pvclal?tipuLHn.ns�
SECTION 9: PROPERTY OWNER AUTHORIZATION s/l]
.;,i; .0 l Wdrlf . 1 ' . ,vrty l) y7er� / a. i ` "c•-Q� . . �L] J j / ®� G ��
.N.tmr(Print) No.and Strivegff
Cih•/ rown _.Lip
I'n t %nr �mta Informalum:
rifle Telephone No. (bustnrs) relrphonr Nip. (cell) a-maul addr.,x
II applicable, the property ownvr hereby authorizes
Name StreetAddnc.% City/Town State Zip
lit acl on the pro pert%owner',behalf, moll matters rrlauye to work authorized by this building permit a + +lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If budding is less Ifun 35,OO11cu.fc of emlimW space and/or nol tinder Comfruetiun Control then check here O and Flu Sctvun 1111)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Sta to Zip Discipline Expiration Date
10.2 General Contractor
Iom(\s CoiA,4 C k oc�
`- 1�mp^y Name: G �S 1 csz 4
I` Na La of PersonRrs mstbir fur Cu slruc w I License No. and Type if Ap licable
Mok)m_ Q�,,�IC �� /��onc�c.�e S� �ocdls5�0 (Z
$ eg.Q reie� f tc-� 1 �� City/Town ,� ! Zip
"�� ll, h I -r 1 �,r
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WO (M.G.L c. 1S2 9 2506))
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? Yea O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=f
1. Building f &Z. O Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical f 0 0 Q appropriate municipal fa tor)=f
3. Plumbingf f,00 d
4. Mechanical (HVAC) f 3 ®cam Note: Minimum fee>•f (contact municipality)
5. Mechanical (Other) f -
Enclose check payable to -
6. Total Cost f 4 Z D (contact munici alit )and write check number here
SECTION 3:SIGNATURE OF BUILDING PERMIT APPLICANT
Its a•ntrnnK my name below, I hereby attest under the pains and penalties of perjury that all of the information cont.unrd in this
appiicatinn w true•cod acccuurraatte�t t the bell of my knu vImIgrand understanding.
��
1'leo.e print and .ign name rule relephune.No. Date
'4t�•t .\J n•.. C'dci Tun fair Zip
AfM c
,
%lwticipal htspectur to fill out this section upon application approval: U f�
\'sine / If,tte
fo
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