9 CURTIS ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
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Department of Public Safety
a. '/'•j \Ia.:adnnvue 41alr Building Code 1•-SU CVIKI.,rvrnth E.Luun !
City of Salem
Building Permit Application for any Building other than a 1- or 2-Fa w Ilin
(Fhi,1c lain For Official L'.e Onlv) I lily
Building I'ennil Number: Data Apphed: Budding Inspectur:
SECTION 1: LOCATION(Please indicate Block s and Lot s for locations for whi tree d to - +b1ei
•
.N." .utd Street C itc /r....it Lip Code Name of B..j1t0<1W apphcablr)
rDed
ECTION 2: PROPOSED WORK
If New Construction check here Our check all that apply m the two rows below
Building❑ Repair❑ Alteration O Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
of Use ❑ Chaneeof Occupancy ❑ Other � Specify'
Areing plans and/ur curutrudiun documents being supplied as part of this permit application? es ❑ Vum
Independent Strudural'Enginrrrng Derr Rrvirw required? Yes ❑ No v
Description of Prupovd Work: f'eR-- lAION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,ORCHANGE IN USE OR OCCUPANCYre if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
se Group(s): Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: 1 Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Sturies(include basement levels)&Area Per Floor(sq.ft.)
Total Area(xl.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a Ifcable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1.3❑ 1-4❑ M: Mercantile❑ TR. Residential R-1 a R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Sprawl U�:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ is IIA ❑ Ila0 IIIA ❑ 11180 1 IVY 1 VA ❑ V813
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0-for details on each item)
Water Supply: Flood Lane Information: Sewage Disposal:
-Trench Permit: Debris Removal:
Public❑ Chrd d,�ubidc I h•,�d Lnnc❑ IIh1l Plte muniapal❑ '\ trench will not be I_Icrmc.l Untn...,I?ur ❑
«•qulrc•d ❑or trench -.r.pccrfv:.
1'n Tale❑ ur indcn blc Lme:_ nr,m�itr�c.lrm ❑
prrmrt i.cnrhr.rJ ❑
I Railroad right of-way: ffaaards to Air Nbvigation: ......-,,..,r,..
\, 1 \ Ipuhlo❑ I.IIructm, ohm.w rl., •u,.,dt.trr.t' I. lltvvr rc,ic„ o" n Ich'J'
t'1' -V"' lI I
.., 1 . n-.ant„ Igidd cm6 -c.l❑ lc.❑ I•r.\o❑ lr• ❑ ❑
SECTION 8:CO,%iTENT OF CERTIFIC,\TE OF OCCUPANCY
I .lilu nl ..11 ..,ly .__— �'cld.•ut•rJ _ r,t•c,-ll � ndrti•lun .__ t k c,l•.tril l . .,.I t,, I
Ii.r. IFr Iltmo.w �pnn klvr?t dom'' _ `l" ,.,I�npu lalu __—
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SEC TION9: PROPERTY OWNER AUTHORIZATION
V. nr.tu.l :\,LIr cal I'rnF•crty l)hnr
Name IPrintl V'u..ux1 Nra•el Cih r rinan Lip
Pn,perty lhanvr Contact Information:
Title reiephene.No. (bushes ) irlrphanr.Vu. (cell) ,•-mail .t d,l n•..
If applicable, the pruperh -nc ner hereby authorizes
r
.- Name Street Address Cih'i T....n State Lip
to act+cat the +nt+rrh •n.na•r .behalf. Ii all matters«•lunar lit work authunn•d by this bud,lin • rrmtt a + bc.t u+m.
SECTION-10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(II tnuWm•os Awe than 75,taaliu.ff.of endusad.+ace and/or nol under Gm>Inodwn C+uarvl the.,check here O and kip F,lovn lot)
10.1 Registered Professional Responsible for Construction Control
Vamr rgistrant) Tnlr. nr u. Ur-mall ad- 1— Re Istratian Number
I y
.�2(srtC� (I)aKe.�?AIL� � o /
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
o any Name:
NI Epirsim Res msi¢I r Construction License No. and Type it Applicable
lr t ddr �f City/Tow �Y
( �State Zip
iv3L- ci yA—
V
Tele hone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'CONWENSArION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) _$ ,
1. Building S BuildingPermit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal(actor)_$
3. Plumbing S
d. Mechanical (HVAC) S Vote:Minimum fee=$ (contact municipality)
5. Mechanical (Other) S r� Enclose check payable to
fi. Total Cast S (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enfr In); Y- c L•eluw, I hereby attest under the pains and penalties of perjury that all of the mfurmation.i.nt• fined on this
.Ij,", a u . na ccurale to the best of my kno,c4ed);n and undersLmdmg.
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\Iunicipil hrspector to fill out this section upon application approval: -__