0027 CHARTER STREET - BPA (006) y:
The Commonwealth of Massachusetts
Department of Public Safety
ti���,j \1,L wtdaux•lle State Building C•.n1r 1%'d0 C\IR)I wenlh Edition
City of Salem I
Building Permit AEflication for any Building other than a 1-or 2-Family Dwelling
{This liection For Official Use Only)
Budding Permit Number. Date Applied: Building Inspector:
SECTION is LOCATION(Please indicate Block 0 and Lot R for locations for which It street address is not available)
2-1 ( hnrFcrS4 Q0,19M 0IA]0
No.and Stmet C its• /Town Zip Came Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check hem❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration •1 Addition❑ Drmolitiun O (Please fill out and submit Appendix I)
Cha nge 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 Reviewrrquir ? tt� C� � r Yes� ❑ No ((
-N
Brief Description of Proposed Work: mo r!{:Ib
SECTION 3:COMPLY THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
N CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O r
Existing UseGroup(s): Proposed UseGmup(s)-
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SEC[iON 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 S:USE GROUP(Check as a licabie)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 O A-4❑ A-5❑ B.
Business ❑ E Educational ❑
F. Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2❑ U= Utility❑ Special Use❑and (rase describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1118 ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
I Trench Permit:NIA Debris Removal: N(I�
Water S ply: Flood Zone Information: / Sewage Dispos ,\lunch avilI nut lice Licen",I Di>)a.s,d Site
f7
Public❑ Check d uul.ide I9ai..i Zone 0 Indicate municipal❑ required , it trench or.pectic:
I'nratr❑ ..r mdrnbfc Zone:_ or tin.dr>a••erm ❑ permit i>ench,. i❑ _
1 Raiimad right-of-w✓ay: Hazards to Air Navigation: \b� I6-h.ri, c .•nuni..um iL+..., Pn•.v
! \tit -1t+l+hcabk 67 LcImciw'c..ithm.urf..rt att•ry�.ich..n.i.' h their«•a icac c.anfdctrd.+
'Irk •n�rnt to Iknld cndo.r.l❑ I I1- ❑ .r Xis id Yc•.O \n ❑
SECTION 8:CONTENT OF CERTIFICA TE OF OCCUPANCY
L,e llrnupt.r f,peat C.in.lrucuun: ticaipan[ l�ad per fli.+r
I) tl b I I q nut t tier nAivr�a�trm,. :praal m pulauun.
SECTION% PROPERTY OWNER AUTHORIZATION
Name and Address of Pruperiv Ownrf �a/n OI/, 7D
Cad O'W Ehs(a�rtit 2 r tin set W,Y 1
Name(print)n
No.and Street C ih'/Town Lip
pn,prrtc U,c'nee Contact Intormatiun:
n b o -17a& 1h-'8—-AL- — -- —
Title Telephone No.Ibusmess) Telephone No. (cell) a-mad address
I('.,r•plirab{•lye,�the pn,prrty menu hr(rhiV�authurttr. v 109
(V�0'n'l�hl'� `LYIV
Name Street Addrras City/Town State Zip
to act on the .ro�erh owners behalf,trial[matters relative to work authonzet/by this buildin• +ermu., •,liauion.
SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
(if buildin•is lay thin 33,000 cu.h.of cnclostd s aw and/or not w,der Cane'truown Control then check here 0 and ski Section 10.1)
10.1 Registered Professional Responsible for Construction Control
ail ft xr ( n�� t o n �401 -D� mCr�f wn e�i sect o net AO313
Name Registrant) Trlrpl7�nr Nu e-mail address Re�jistratiun Number
ap,IvrrulyflA `. �UCCt I�YbV1C�P�"P Za "`�1
Street Addr`cv' ''�"" City/Town `_state Zip Discipline
Expint un Date
10.2 General Contractor net
AI y nm..,. o> ,r titans onj- OJ Imo.
1 utlt,.ttsr a � �Q� I
Cum
pa. Nam n Iail� CS A D&
Namrt Prrsu Res"'unslibUl,fur�unsl„n,ctiun ^•��^hnn4crnse No. and Type ifPpplicable,r,�
StCity/Town
(1 ��
St t Address City/Town State Zip
leS1b -- j Q� �^dn�wtaF ADM
Telephone No.(business) Telephone No.(cell) - e-mail address
SECTION it:WORKERS CO SAIION INSURANCE AFFIDAVIT(M-G.L e-152. ISC(6))
A Wurkers 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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
I
temEstimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S�_-
1.BuildS Building Permit Fee=ToOD
tal Construction Cost x_(Insert here
2.Elect $ appropriate municipal factor)=S
3. Plum $
4.MechS Note:Minimum fee=S (Contact municipality)
5. MechS Enclose check payable to
6.Total S �- (contact munici lit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this
application is true.md accurate to the best of my knowledge and understanding.
�1V1 U tI lPX1lP t IIL'�VYU �Y`t Q Neat'Lk ' 6`0 4q5
f' •.nr pant.cod sign name rifle ralephone Nu. Date
t7 - VUQ C No f Wk -I""1
vn•.y ti.in... CiI.%;T.n. Sate Zip
i I
i
Municipal Inspector to till out this section upon application approval:
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