0027 CHARTER STREET - BPA (005) r
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The Commonwealth of Massachusetts
A, Department of Public Safety
YV, ' 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)
fC�^) 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)
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No.and Street City/Town Zip Code Name of Building(1 applicable) _
SECTION2 PROPOSED WORK
Edition of NIA State COLIC used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ I Alteration Addition❑ Demolition (please fill out and submit Appendix 1)
Change of Use ❑ 1 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 De cripti no Proposed Wor :. t_ C-
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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 CNIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Totil Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ F B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Huard H-1❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
1: Institutional 14❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ ILA ❑ LIB ❑ ILIA ❑ IIIB ❑ I IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public❑ Check if outside Flood Zon ❑ or
e Indicate municipal❑ A trench will not be P s
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �I n I I. 1 rn'1pmn n I rviu I r .vw;
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 6:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: _Use Group(s):. Type of Construction: Occupant Load per Floor: —
Does the building can twin an Sprinkler System?: __ Special Stipulations*,
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SECTION9: PROPERTYOWNER'}UITFIORIZA'TION i
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zn
Property Owner ontact Information: \\
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 property owner's behalf, mail matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
!f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
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Company Name 144A StaArn
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Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town - State / Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:IVORI FK.S'C)MPhNSAI'ION INSURAN0:AFFIDAVI I' 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 lhis application. Failure to provide this affidavit will result in the denial of the isy(ce of the building permit.
Is a signed Affidavit submitted with this application? Yes No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Estimated Costs:(Labor
Item and Materials) Told Construction Cost(from Item 6)_$
1. Building $ S OS Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (FIVAC) $ r 000 Note:Minimum fee=$ (contact municipality)
5. Mechanical Other ,"+ Q Enclose check payable to
6.Total Cost $ 6 (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.
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Pleas r t a ''gn nan Title Telephone No. Date
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Street Address City/T St Zip
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Municipal Inspector to fill out this section upon application approval: + 3 O
Nance Date
QTY OF SALEM, MASSACHUSEM
t,+ BUILDING DEPARTMENT
3 120 WASMNGTON STREET,3ADFLOOR
TEL(978)745-9595
KMERLEYDR MLL FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#t
with the
Is
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
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Date