21 CHARTER ST - BPA (002) The Commonwealth of Massachusetts
, Department of Public Safety
V1aSSAChusetts State Building Code(780 CMR)Seventh Edition
City of Salem `
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(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)
AJ C#/RRT6i? s r SWEM Hi3 6/ 970 67OVI, ( iL-Y vt 0
No. and Street City /Town Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
r •If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 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? Yes ❑ No ❑
Brief Description of Proposed Work: 4-4 FA00R' d941 BF1JI2oc+/r/
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❑
L• Institutional I-1 ❑- 1-2 ❑ I-3 ❑ .1-4❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3 ❑ R-4❑
S: Storage S-t ❑ 5-2 ❑ ` ti 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)
Water Supply: Flood Zone lnfomiation: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check i(oulside Flood Zone ❑ Indicate municipal ❑
A trench will not be Licensed Disposal Site ❑
131 i 'Ite ❑ or indentifv Zone: or on site system ❑ required ❑or trench or Specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %IA I Ii,uon, Comm,»ii.n Rocioc Pro;r..:
Nut Appli-cable❑ IS Stnidure 3%ithin airport approach area? Is their review completed?
r h
ur Cun*ent to Build enclosed ❑ Yes❑ or No ❑ Yes ❑ No ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of C ndr: LSe Group(.S): Tvpe of Construction: Occupant Load per Flour:
DocS the budding contain an Sprinkler Svslem?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION '
Nome and Address of Property Owner p'e f Ek sr 5da04 !
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Name(Print) No. and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
:Name Street Address City/Town State Zip
to act on the pro perk owner's behalf, in all matters relative to work authorized by this building permit application.
y • .1 , SECTION10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu. ft.Of enclosed space and/or nut under Construction Control then check here❑and skip Section lll.t)
10.1 Registered Professional Responsible for Construction Control
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Name (Re nstrant) Telephone No. a-mail ad re ss Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Coro�pany Name: '
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Name of Person Responsible for Construction License No. and Type ifApplicable
S reet Address City/Town State Zip
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Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIg6VIT (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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 4eO VOA Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ J� 7 (contMunici ilit
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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 and understanding.
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Please print and sign name Title Telephone.No. Date
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Street Address Cite/Town St e Zip
Municipal Inspector to fill out this section upon application approval v p
N me Date
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