12 CURTIS ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
4 t Department of Public Safely
;„I \Lt.:adao•e Is State Budding Code 1,SO 0.110\•ern I Edmun
City of Salem
Building Permit Application for any Building other than a I- or 2-Fimily Dwellin
(rho"eitlun For Official U,e On IV)
thudding Perrot Number: Date Applied: Building Inspector:'
SECTION 1: LOCATION IPlease indicate Block a and Lots for locations for which a street address is available)
IJ- J!�crat-! 's SA
No. and Streel Cltc /T...'n Zip Code .Name of Building lit applicatOR
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply m the two rows below
--_-- ---Exist mg-Building � . -lapair-❑--AIteration-0 —Addilxm-❑Change of Use ❑ Change of Occupancy ❑ Uthrr ❑ Specify:
Are building plansand/ur cunstructiun documents being supplied as part of this permit applica l ion? Yes ❑ Nu Is.tn Indrprndenl Strutlural Engineering Perr Review regwred? Yes ❑ Nu Brief Drcnptilin of Propos d Work:SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITIO
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazird Index 780CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Propused
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(.sal.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a pp
licable)
A: Assembly A-1 ❑ A-2r ❑ A-2ne 0 A-3 ❑ A4 ElA-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 0 H: HI Hazard H-1 0 - H-2 Cl ❑ H-4❑ H-5❑
1: Institutional 1.1 0 1-2 ❑ 1-3 0 1-4 CI I- Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑
S: Storage 5-1,0- 5-2 ❑ U: Utility❑ Special Use 0 and pleas,e describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IBC) IIA0 Ilea -IIIA0 111813 1 IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer Io 780 C.NIR I)1.0 for details on each item)
Water Supply: Flood 'Zone Information: Sewage Disposal:
French Permit: ' Debris Removal:
I'ubhc❑ ChccC If Anil>alv 1 InJlcnr mumapal❑
A Tench will not be Llcrncd Unto•,.il�ilr❑
- n•yuucd❑or trench ��r.pciltc
m .
Ih'Iraty❑ r Jcn file Lrmr: ur�m�dr�c•trm O
I - )`rrmrt I.cnclu.e.l ❑
i Railroad righl-of-way: Hazards to Air A'avigalion: \ba IInL.n• t ...............11<.,„., I•,.,,
I -
'\rl \PI•b..11drQ 1.`Irwlwrlt illnn.ur)nrtl.I p,•lu.ida.rrr.t' I•lhcrt n•.ic.t : nnld.IcJ'
.. 1 •n..'nl b•Itw .l cnaL•vvl ❑ lc•❑ .a\n❑ lr.Q \ Q
— i
SEC"iIUN A:CON TENT OF CFRTIFIC.1 fE OF UCCCPANCY
I .Iduil •I IyIC . .__ L•cldrlt4�1 ft F`c.•I\ .Irli that .___ ltiilll`.Illlln.11 f•rr lien -_. _-_._ ..__.
16,r. Ihr 1`udJuq. •nLtiP.m�InnLlrr�\.It•m'' _ ?l•cclal`IipUl.l ur•n. ___ ..___._—_—_--__ I
l
Ali`
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SECTION 9: PROPERTY OWNER AUTHORIZATION
N,mlemid AdJrv..,,l I' ul•x•rty 0%,ner
\,m,r lPnnt) No.,Ind?Irvel t, ih, r,nen hf,
Pn,perty th,ner Contact Inlormat,on:
rule Telephone No. (bu,me>s) relephone No. (cell) .•-m.nl aJ.lrr..
Il.,ppbc,blr' t/�y!.p/rof•rrlc owner hrrrbv authortrrs R//� -
Ci;.t�ati 93/✓4r dY Etw �T /IA! r� f nz)
Name ) Atrcrl AJdre>s Cavi Torn Stole Zip
e,acl,m the +ro •erty ot,ner behalf, m all matters relati%e to ourk .nrthunta•d by this buddln • rrnut a + hiauon.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
111 t•ud.bn•I.los(tun lVXX)cu.ft.of endonJ.+ace and/or 11,11 under Gn,>tr,w hun Cuntml then check here O aml-k, +St•.Inm Ill I I
10.1 Registered Professional Responsible for Construction Control
M14. -10.1 9I- S71- 40s6 Loyal
),s r rp)unr u. r-mar a r Registration Number , /,
/•ba 7CIrar�cii•� d✓P in wvl/ ss 1A^ -Z/, ,-`L_
Street Address City/ own State Lip Discipline Expir,, Date
10.2 General Contractor - -
901 eo j)76>
Cump��any N,,,l2.Z�
Name of P
e
rson Res mstble fur C�nstruct�iu Li No. and Type it pplicable
Street Aad ss — �r a"� .
City/Town State - Zip
—
Telr hone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT(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 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? Yee O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
I. Building $ SO Building Permit Fee Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
3. Plumbing S
N. Mechanical (HVAC) S Note:Minimum fee=$ (contact munici ality)
S. Mechanical (Other) S Enclose check payable to <
6. Total Cost S . IF 50 contact
munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Rv entering my name below, I hrrrbv attest tinder the gamsand penalhry of prqury that.ill of the nf,,rmation o,nt.iine,l In this
applicaton I.truee aann-1d accurate to the best of ms• knowledge and unders6mdmg.
I'I •Le ,elm.I f"g an• .. __
ja F ,,; `�'- '� �q--- /J�,/��y r r ���rvlcph,m, V, ()ale
III rt Wdry �Yu I //`(I--
l�lfs:7.,tt rt �Lllr Gp
i %funicipal Inspector to fill out this section upon application approval: -_ !
\,unr Ilse ,