12 1/2 - 14 DANIELS - BPA B-13-713 INSULATION �y The Commonwealth of Massachusetts
�, I•-/ Department of Public Safety
�`.,., ,�„.l' .Massachu101.1 State Building Code(780 C\IR)Seventh E, turn
City of Salem
BuildingPermit Application for an Buildingother than a 1- or 2- ily Dwelli
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspectors
SECTION 1: LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available)
/7- 7 z- k /'� _ 11i a,,. A -7 61--7
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair ❑ i Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: /5,. fa (.-01
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: 4)moo ,.lL_�- S-Lr�fS
A;r S
('� .a.r� i ,.�/ ,. ri•.-r f;.la./ S 2 %5— %f -. . r , h> /cam-JSf
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 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 5:USE GROUP(Check as applicabie)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hierc Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4 ClM: Mantile❑ R: Residential R-10 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 applicable)
IA 180 IIA ❑ 1180 IIIA ❑ IIIB ❑ IV ❑ 1 VA CI VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ Chuck it nubidc•Fluud LimC❑ IndlCate municipal ❑ A trench will not be Licensed Disposal Site❑
.pccily:
I'ri,ate❑ ur indenlife Zune:_ or on .i to Nea required ❑or trench urem ❑ permit tN enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I li+hm, Rrcu n I'ro'
.Nut Applic.d,le Cl I.tilnic lure,c their Ie%ie%N completed.'
rt C1-ment hr Budd endmcd ❑ YeN❑ or No❑ Yes❑ Nu ❑
SECTION 8: CONTENT OF CERTIFICA FE OF OCCUPANCY -
I duion of Code: L:,e(;wWpi.i: rtpcof Cumtrucuon: Occupant Load per Flour:
I)orNlhc•buildutFrnnlau+anSprinklcrtitNlcm': SpccialStipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Ne and Addree of Properly Owner
Icy �� tvSJtil /2//O,/l� C7oMti'�5 /c� LG�
:Name(Print) Nu.and Street City/Town Zip
Property kNk ner Contact Information:
oW?x � - -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the pro arty owner hereby author s ,M
Er, F�('=h 3 il. r
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work,udhorized 6 this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It buildin g is lens than 35,LX)U cu. ft.of endusCd s pace and/or not under Construction Control then check here O and skip Section ILL 1)
[:::
Re Professional Responsible for Construction Control
rN `�)s -�1q - 8i73 -rP&1./n at`�mta II /`l�6a�nt) �,q Tele 7bon No. a-mail addre ss "IveRegistration Numbr %City/Town State Zip Discipline Expiration Date
Intrac�torr
Name of Persu orisible for Construction License No. and Type if/es Applicable la
3 r1�7 esp� sf- Salmi ., 4M Ofi
Street Address City/Town State Zip
78 - - R/ti.3 _L - 72` - /03! "T'P Ci �Cz,rr�r�sF- - N�;4
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION 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? 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 $ Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical $ .appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
I 5. Mechanical (Other) $
Enclose check payable to
6. Total Cost -- $ 5666 . O c (contact municipality)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 istrue and accurate to the best of my knowledge and understanding.
I'Ir.t.c pr nt arm ign name ride TClephune.N�o. Date
Co l� � &,A:eQ At C/"27 e)
titreet Address Cilci Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Dale
,n -