0027 CHARTER STREET - BPA (003) NI
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The Commonwealth of Massachusetts �lv sty C
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
27 CNAaTD2 57t6£7 SALEM 615-70 SA46M NOvAtW-2 g0WdAr7Y '
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ 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 of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes k No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: 3usrAt4.ATZ%(V AC q,YIENM J5 AKD "AT6S g!Ag C &Z TE2 CdE
MA5MLSSSJ AlX41C1,vA�AI -r SE& "TSett/ t-
.y EAutPw.GA/r ya£LTER
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) W�*
i
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1.❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage Sl❑ S2❑ U: Utility Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ HIf ❑ HIA ❑ II1B ❑ rv ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the budding contain an Sprinkler System?: Special Stipulations:
02-6J
/ SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
SAa *l "bili' w AvMilill 21 C"AMIZ SrA6 T SAL45VA
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Ekecursve bXA6=L 99g_�YH_ H431 CKtgc�ow,yESALE140A.o12/.,
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 1yoperty owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here7mb
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registra
Street Address City/Town State Zip DiscipliDate
10.2 General Contractor
NAN6PAsHEA,l PRAJEa AMAIAZIBi1d�A/1" SNG
Company Name
JAVA/J A/es769 CS Oy7636
Name of Person Responsible for Construction License No. and Type if Applicable
32J8 !n/,c'Si Staot¢er DA1/E it!!4✓ iZCHE40 AIA 0/9ys-
Street Address City/Town State Zip
bslb 781 - 12.1. 65tb csko�nanc�+tsha+c
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INS:UR�ANCE AFFIDAVIT M.G.L.c.152§25C 6
A Workers Compensation Insurance Affidavit from the MArtment of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidaviresult in the denial of the issuan of the building permit.Is a si ed Affidavit submitted with thilication? Yes❑ No
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $ NOke:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �7 r(70 (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 in this
application is true and accurate to the best of my knowledge and understanding.
- ' //n i
Please print and sign name Title Telephone No. Date
328 Ly65? SHAH',Ai /�f.4/4[�isF.9D 6 FYS
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date