25 CHARTER ST - BUILDING PERMIT APP 1�,� 1 1
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� The Commonwea�th of MassafAfifs`�f�� ���4G�
, n4� Department of Public Safety
M:issachuseltsSthteBuildin C�xle 780�j� ���
Building Pertnit Application for any Building other than a ONe-�oJ'Y'w�Fam�il1y D e011��ing
.(This SecNon Fur Official Use Onl )
(J BuilJing Pcrmit Nwuber. Date Applied: Building Of(icial:
�O SECTION 1:LOCATTON(Piease indica�e Block M and Lot N for locaHona for which a street addresa is not available)
� S D tS�le�.�lvu�t�x. �¢� o.R��•v
, No.anJ Street City/To�vn Zip Cale Name oE Buil ing(if applicable) .
'� SECTION 2•PROPOSED WORK �
' EJition o(MA S6�te Cude us��l If New Cunslructfun ch�ek here�or check all that apply oi the Iwo rows beluw
� Existing Building Repair O Allcratiun AJditiun❑ Demulifion O (Piease fill out and submit Appenalix t)
� Change uf Use O Change uf Occupanry O Other ❑ Specify:
Are builJing plans and/or cunstmctiun ducmnents being supplied as part of this permit applic.ition? Yes No O
Is an IndependentStructural Engincerin,Q�Peer Review reyuired? Yes O No p�
Brief D� riptio�yof Propus�1 Worlc. ES PMfiU:? b�+�iC � i r f6i.@ Q
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SECTION 3:COHIPLETE TH[S SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDl7'ION,OR
CHANGE IN USE OR OCCUPANCY
Ch�Yk here if an ExisHng Building►nvesHgallon and Evaluatio�is enclosed(See 780 ChIR 34) O�
EsistingUseCroup(s): ' Propos�.dUseG`oup(s):
� SECtION 4:BUILDING HEIGHTAND AREA
. . . . Exisfing Propose�l
(Vu.of Floors/S�uries(include b.uement levels)&Area Per Floor(sq. ft.) �
Total Arca(sq.ft.)and Total Height((t.) � .
SECifON 5:�USE CROUP(Cheek as a Ilcable) �
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5 O B: �Uusiness ❑ E: EJucallonal ❑
F: Facro F-1 O F2� - H: Hi h Hazud H-1 O .H-2 O H-3 ❑ H-d O H-S O
1: (natituNowl I-I O. I-2❑ 1-3 O 1-4❑ M: MercanHte O R: Residen�iat R-1❑ R-2❑ R-3❑ R-0 0
S: Storage SI ❑ � S2 0 U: Utility❑ Special Use and lease describe bcluw:
Sp��ci;il Use: � 2JZ
SEC1' N 6:C NSTRU !ON TYPE(Check as a Itcable) � �
G\ O 16O (IA ❑ IIBO IIL� O IIIBO NO VA ❑ V00
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for detalls on eac6 item)
6Vater Suppi Flood Zone Inform�Non: Sewage DisposaL• Trench Permih Debris Removak
Public� Ch�tik i(uutside Fluod Zune❑ InJicah municipol❑ �trcnch will not be Licensed Dispusal Site❑
Private O or inJenlify Zone: ar on sile system❑ rcyuireJ O ur tnnth or specify:
. Fxrmit is endosed❑
Railroadrightof-way: HuardstoAirNavigation: \I�\I,1„m��r�_.��nni�.s��mK;�_u•g:.l'nk�,p:
Nut Applicable❑ Is StruUure�vilhin airport approach area? Is U��ir review cumplehd?
ar Cunsent[o BuiIJ endosed❑ Ycs O or No❑ Yes O No ❑
SEClION tl:CONTENT OF CERTIFICA'fE OF OCCUPANCY
[ditiunu(Cu�l�: UseGrnup(s): TypeoFConstructiun' OecupanfLoadperFlnue
Docs thc builJiny,comain.m Sprinklcr Systcm?: Speci,J Slip�datiuns:
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SECTION 9: PROPEA7'Y OW(YER AUTFIORIZA"CION �
Name and Address of Proyerty Owner
�?5'c.���a., S f— ��s�-� rt� C�1 r7o
Na�ne(Print) � No.and Street � City/Town ZiP
Property Owner Contut lnfonn.uion: C H�� �5����� �O �
�'.�-�� `����'e� �-7�1,6' yS�9.� - - r ',
TiUe Telephone No. (business) Tclephone No. (cell) �mail address �.
If app/�lica}ble,the property owner hereby authorius �
��. [rJ1 /-C��It�� - ��..
N;une Street Address City/Town State Zip
to act on the ro er uwner's InHalf,in�ill matters rclative to work authoriud b this buildin ermit a lication.
� SECTION'10:CON57'RUCTION CONfROL(Please fill ou!AQpend&2)� �
If builJin ie Iesa thnn 35,000 cu.ft.of enclosed s m anJ or wt under ConshucNon Control then eheck here O and ski SecHon 30.1
� 10.1 Re istered Profeesional Rea onaible for ConstrucHon Control �
Name(Registnnt) Tclephone No. c mail:�aldress Registration Numbcr
Strcet Address � City/Town Sl.ite Zip Discipline Expiration D.rie ,
10.2 General ConMactor - - - � � �
0� ' 1- .
�C p<iny Name
�'��b(�— c,�os��3 �,�po��;��.��—
ame of Person Responsible fur unstructiun Littnse Nu. and Type if Applinble
�jt�P�.��r �¢.,-p .gea�nQw .b� c�o�j.� .
Stmet �Address —� � City/To , State Zip
7�-� �'� `���`�- �1�— ..." ' �� c�r,c�.s� "v,el� -
Tcle hone No. business Tde hone IVo. cell e-mail addmss
SECTION11:4VOFFEhS'COAIPENSAII(JNINSUR:�.NCF..4PFIbAV17' M.G.L.l.752 25C6
A Workers'Compensation Insurance Af(iJavit from the b1A Deparhnent of Industd:il Accidents must be mmpleted nnd
submitted with�thta applicafion. Failure to provide this affidavit will result in the denial of the issuance of the building permit �
Is a si ned Affidavit submitted with this a licaHont � Yes 0 No O
SECIION 12 CONS7HUCftON COSTS AND PERMIT FEE
Estimated Costs:(Labur
Item ���������� To1:il Cunstruction Cost(from Item 6)n$ Q� �
L 6uilding g �0 guilding Permit Fce=Totaf Cunstruction Cust x_(Insert here �
� 2.EI�Ytrical S � S�t)wG � :ippropri�te municipal facror)_$
1. Plumbing $ � .
d.Al�tihanical (FIVAC7 g Nute:Nlini�num fee=� (mnlac[municip:ilitY)
5. M�cAanic:J Othcr � � Endusc chrYk a ible tu
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6.Total Cust $ p��b0 (contad municipality)and write check number here
SECI'ION 13:SIGNA?UR8 OP 6UILDING PERh11T APPLICAM
6y entering my name beluw, I hcreby a�test wider the pains and penalNes uf perjury that all of[he intorm.tiun cunfain�tl in Ihis
application is true.md accurate ro the best of my knowledge anJ understanJing.
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� Pf�::ue mt and sign mm�e , �— Tille Tclephune No. Date
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Slrcet Address Cily/Toi State - Zip
�Ivnicipal Inspector to fill ouf this section upon appiication approval: � /
Name Da�e
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. ) Mars�all 5[reet
. Boston MA 02108
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COMMUNITY ROOM " � '' "', ^'� Fe��m�� 8��.�Zo.�zaZ
REMOYE EXISTING SIIRFACE � ( I www.blecksmneblocx.com
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OFFICE RENOVATION
EXIST. WORK STATIONS ��` . !E> �� STOR.
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J � � ALLOW ROOM FOR NEW F �`> �
/ HIID FlLE CABINETS _ �� 27 Charter Sireet
� EXISTING ,i Salsm, MA 01970
' � UIDRK STATION - -
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EXIST. WORK STATIONS HANDRAIL � WALL 8 (E) ' STOR. �
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HUD PIIE CABINETS ��.
� � ' EXISTING � - �� � � 27 Charter Street
� — WORK S7ATION � - -' --- ��"�� Salem, MA 01870
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