22 DERBY ST - BUILDING INSPECTION JACKET The Commonwealth of Massachusetts
F: I Department of Public Safety
`.'J %Iapsachlbelt5 State Bu Jding Code(780 C\1R)Seventh Edition
City of Salem . -
` Building Permit Application for any Building other than a 1- or 2-Family Dwelling
\bl (This Sa'ctiun For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION l: LOCATION (Please indicate Block N and Lot N for locations for which a street address is notavailable)
.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,0 Repair❑ 1 Alteration ❑ Addition ❑^•- Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Cl No )g
Is an Independent Structural Engineerin, eer Review required? O Yes ❑ No I
Brief Description of Proposed Work:
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): Y
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 applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard fl-I CI u H-3 ❑ H-4 ❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility Cl Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1111 ❑ IIIA ❑ I►IB ❑ IV ❑ VA ❑ 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 ❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not he Licen.ed Di*posaI Site❑
required ❑or trench or.pcClIv:
I mart•❑ nr mdvntilc Zone: or on ate sv.tem ❑ permit is vnclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I•\ 1 tin,nr lnnmi��im
\ut \pphcohle❑ I. thtn airport approach area.' I. their review cumpleted7
"I to Build enclosed ❑ 1'v.❑ or .No❑ - Ye. ❑ \n ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
I[.hu,m of Cede: L.c Group(.): re pe of Con.tricuon: occupant Load per Floor:
0-�,— the building contain an Sprinkler Salem.': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION p
N e antd t C`�A,,dd ass of Pr , rty Owner c>1 ,/.y'\ 6`p( Q
� _
Name(Print) No.and Street C itc/Topvn Zip
unlac lln formation:
LL7
2�
Title Telephone No. (business) Telephone No. (cell) a-maul address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to acton the pro pert%owner's behalf, in all matters relative to work authorized by this building permit a p ,bcation.
SECTION 10;CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,001)cu. Mot cndosed space and/or not under Construction Control then check hen❑and skip Section I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contract r
It S il-n
C any Nam )1 /—�l C.f
if it2�
Name if Pecs. Ile port.+'i�r Construction V ���y License No. and Type if�App abl���6�
t d ettl City/Tow ,�,d •nl\ �Staj� Co C4` he�
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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ b Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) =$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact rp nicipali y)
Al 1
5. Mechanical (Other) $ Y h
Enclose check payable to l���C-� V
6. Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name beluu , I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is trine and , i to to the best i my knowledge and unde—rsttaanding.
'C e/
1'leasr print andsi •t n i e \ ritle Telephone Nu. Date
0.1
SUrrt :\ddress City;'Town Sto to Zip
Municipal Inspector to fill out this section upon application approval-
Name Date