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88 DERBY ST - BUILDING JACKET L The Commonwealth of Massachusetts gftildffing Department of Public Safety Massachusetts State Building Code(780 ClvIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) O t Number: Date Applied: Buildumg Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 'St�An-av S� • 15nl,E� .�+4 cha7o SAY p47uS&, p*? t_ No.and Street City/To%vn Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK 1 Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below ,fl Existing [luildingg Repair 1 Afterationg I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ I 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 Review required? Nu ❑ Brief Description of Proposed Work: 1jo CCA 13g440,20A- ::FM SECTION SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): 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-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ r\-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ IL• Hi h Hazard H-1 Cl H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 14 Cl 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2 Cl R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use. SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ 111\ ❑ I1111 ❑ 1 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 be Licensed Disposal Site❑ Private❑ or indentify Znne: or on site system❑ required El or trench or specify:permit is enclosed Cl Railroad right-of-way: Hazards to Air Navigation: T Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Constriction:_ Occupant Load per Floor:. _ Does thee b/uildine contain.nm Sprinkler System?: _ Special Stipulations: r 1 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 1/Ai J f ��J-rcliy 5 F s�G ., yr� m 9 ,20 Name(Print) No.and Street City/Town Zip ' Property Owner Contact Information: Title - Telephone No.(business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf, in all matters relative to work authorized by this buflding permitapplication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not antler Construction Control then check here 0 and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control MIC- LIR GM-r`F� 44Z---99�9 7 Name(Registranil Telephone No. e-mail address Registration Number /o DF2f_x 5x)C-�, © za Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - C Company Name S'eA t"' leek.. O-UJ -40,zrt�G 7 CS— 0 s 3.9 Name of Person Responsible for Construction License No. and Type if Applicable aC(K 'e-c,2f se9Cc*" -e�w o/9,>eo Street Address City/Town State Zip —_ 9 "-9 9,P Telephone No. business Telephone No, cell a-mail address SECTION11:1b RKF1S'C0Ntl'ENSAIION INSUItANCki AI'FIUi\Val' M.G.L.c.152 9 25C6 A Workers'Compensation Insurance Affidavit from the NIA 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. Isla signed Affidavit submitted with this application? Yes 13 No ❑ 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 $ Yoo-oo appropriate municipal factor)_$ 3. Plumbing 0,0 4. Mechanical (HVAC) S Note:blininumm fee=3 (contact municipality) 5. Mechanical Other $ Enclose check Y°Pa able to 6.Total Cost $ 4/?3 oo D (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. .,x,. cy S Ccs.v f 2�c*�2 9�8-2��'-�� y/S Please print and sign name Title Telephone No. Date aY/ AJe�deItH S5�• 5/ael&.2 MA i v Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date a Commonwealth of Massachusetts IL\ t Citv of Salem YI ?ry i 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x6641 Return card to Building Division for Certificate of Occupancy Permit No. 8-15-222 PERMIT FEE PAID: $297.00 DATE ISSUED: 3131/2015 This certifies that IRISHEA TRUST, LLC has permission to erect, alter, or demolish a building 288 DERBY,STREET Map/Lot: 350260-0 as follows: Renovation BUILD WALL TO SEPARATE SPACE (AS SHOWN IN PLANS) u tI)o-fRNR p ggNi Contractor Name: STEPHEN D. CUMMINGS — � --_;- DBA: CUMMINGS CONSTRUCTION i Contractor License No: CS083956 l G V11 Fi31i Rr ,., 4 C 't -. .! a . rlMi—*a 3 "• � s f� 3/31/2015 �: Building Official i, "' Date This permit shall be deemed abandoned and invalid unlessthe work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. dIiy't i This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. >a( t The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit, 4 4 � ` H IC #: 149576 Persons contracting with unregistered contractors do not have access to the guaranty fund"(asset forth in MGL e.142A). Restrictions: t ' ��" + � :i, 'k 3R „m - _WLs,%.. a:.'c- Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER.