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21 CHARTER ST - BPA b ,\ The'C(immonwealth of Massachusetts �.• I`� Department of Public Safety •�'.;,•;_,„.i' Nlassaduuells State Building Code(780 CMR)Seventh Edition ` City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwelliniz (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not available) �2 / ni/fI rEk, sT 5A1yY 0/970 GOly,E7- FC��'�Al x No.an 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❑ T Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancv ❑ Other ❑ Specify: 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?? J7— Yes ❑ No ❑ Brief D�scriytiun of P,)posed Wur C//.�'Yr9�.- �l«d?r/»� CQ� (Tb•� /�1a-e �C�� 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): - S 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❑ 1 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 ❑ 14❑ M: Mercantile❑ - R: Residential R-10 R-2❑ R-3❑ R-4 ❑ S: Storage S-I ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) 'Debris Removal:,it Perm : Water Supply: Flood Zone Information: Sewage Disposal: Trench - Public❑ Check it outside Flood Lone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ required ❑or trench ursv: Private Cl or indentifv Zone: or on site<vstem ❑ peco permit is enclosed ❑ 1 - - Railroad right-of-way: Hazards to Air Navigation: \In I list,mc chin...... �n K�•,6•�� Pn�n•s: \ot \ppliCobly ❑ Is KlrL1Cturc within airport opprnadi area:' In their review completed' or 6111101t to Build enclosed ❑ Yes❑ or Nn❑ Yes ❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Lse Fcpv ul Construction: Occupant Load per I looe Does the building contain an Sprinkler Svslem?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Prupert_v Owner Ni G©/YEL .21 C,86R7re 1;;—r 5f9ZFM / ,6 �/ o Name (Print) No.and Street City-/Town Zip Property- Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the p7z owner herebv authorizes Name Street Address Citv/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit a>plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 20 , (If building is less than 35,WO cu.ft.ut enclosed s pace and/or not under Construction Contrul then check here O and skip Section I0.1) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address,, Registration Number Street Address City/Town State Zip Discipline ExpiratiodDate 10.2 General Contractor ZY�-5K G®/YSTkuc�Ivff- X uSZ zYsK fJ/e .� /2273`� cs & g'/7�S Name of Person Responsible fur Construction License No. and Type if Applicable /S fgr►J�Ews f�� >f-S-F A ©1?193 Street Address City/Town .L State Zip '7cv-8.3,6 Ge-7 fW -tQ.34 CeZ9 L4S e�ns�.ruv/Oar �n�NeorL �C &r 7 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 application7 Yes❑ No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ lzaoo 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ g,09 4. Mechanical (HVAC) $ S Note: Minimum fee=$ - (contact municipality) 5. Mechanical (Other) $ Enclose check payable to Cs � o � Jam//a-, 6. Total Cost $ (contact municipality)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 m this application is true and accurate to the best of my, knowledge and understanding.. /rY/2�fS2 Z�S� �� a cr�m�trnrFkw✓ �3�6d ., Please print and aign name Tale Telephone No. Date }tfeet Address City-/Tm%n St,t to Zi Municipal Inspector to fill out this section upon application approval: Name 61 Date 3 /'fig l cow&j f'G,-'gel o? l Git/9TE,L> 6-r 31 31 19 FFL (58s) 11 20 ,r CPT 0) UAT SFL 63 FFL 3 5 BMT (1953) 30 SFL S� FFL BM (150 9 poor 2xl" Ippo� sH��+o(Yb s/8 ftf �G� -ArcC2-<fI I Lp 30 y Bapf -sl4wokp G AIR -Vpo� �oocS GRAVE ��