152-156 DERBY ST - BUILDING JACKET r 3 (9c
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 C
Building Permit Application for any Building other than a ne-or wo-Fam' Dwelling
(This Section For Official Use Only) -
Building Permit Number: - Date Applied: Building Of i" _
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whit str addres is not available)
��_ 1 s G 'De r- ` !t4 A\p yn M/3 Of 970
No.and Street City/Town Zip Code Na e of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here O or check a0 that apply in the two rows below
Existing Building 99 1 Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0
Is an Independent Structural Engineering Peer Review required?` Yes ❑ No ❑
Brief Description of Proposed Work: iz ' MQ 2 P <-e "0 A')\e' i.re
II. .' I ..T—
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 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION4: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-2❑ Nightclub ❑ A3 ❑ A-f❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1
H.
Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ ❑ M: Merc 1-2❑ I-3❑ 14 antile❑ 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 ❑ IB ❑ IIA ❑ lIB ❑ ILIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required❑or trench or specify:
Private El or hndentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �L\I liunn\_Conunnsi n Rey-�r \ t n ass:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No Cl
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: - Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION' -
Name and Address of Property Owner
S a ® K-0V A15q Kbr��vh�
Name(Print) 1/�5 vb� No.and Street r� City/Town C�. 9/1✓t /y Q'70, Zip
Property Owner Contact Infdnnation: t 6l� 1 L/(
Ti[ Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes c
—ta ., \ aCk1�i 1 cirv-s S +L Jc,A2 avl
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this budding permit application.
SECTION 101:CONSTRUCTION CONTROL(Please fill out Appendix 2) ,
[f building is less than 35,000 cu.ft.of enclosed space and/or.not under Construction Control then check here❑and skip.Section 10.1
10.1 Registered Professional Res p onsible for Construction Control
c E��w�CU: 4'79735 0557 oG"("�rb
Naive(Registrant) Telephone No. e-mail address Registration Number
4c n c_ 'S ya_. Sci tevvt IVA u_! 7e L• S $1-F- I �
Sheet Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
55
Street Address City/Town State Zip
qqf
Telephone No.(business) Telephone No. cell e-mail address
- SECTION 11:\\Of KE'RS'CO61f ENSA'I[ON INSU RAMC t:-AFFIDAVIT M.G.L.c.152..§ 25C 6 -
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 11 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ -
1. Building $ J�G7, 1 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality) .
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ J rJ 9, c)Q (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.
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Ply se print and sign name ` (� Title Telephone No. Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name _ Date
No �
r �q, $T$EfH.{-b'iiND Af )FIOVED BY T44E
4r II PI:GTO_R .PWB TD.A PERMIT BEING GRANTED
CITY OF SALEM
No y� 6-6 `� ..� ° Date_
Is Property Located In Location of
the Historic District? Yes_,No 111-� Building /t2-46Z DEBT
Is Property Located in
the Conservation Area? Yes_;No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Rep air/Replace, Other: Ac »,-,o
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name Gird �ou✓ c,9� ��J
Address & Phone �S6 ��r�v �T f 7y4/ 7`36 9
Architect's Name
Address & Phone
-----------------
Mechanics Name 9�� ✓�� /1 �r� 4
Address & Phone
What is the purpose of building?
Material of building? If a dwelling, for how many families? I
Will building conform to law? j/zs Asbestos?
Estimated cost City License a<
N�State Line e # e.S �J85r 7
Borne Improvement
S / Ltc. of sys�sG' nature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION/OF WORK TO BE DONE
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MAIL PERMIT T0:
No.��
APPLICATION FOR
PERMIT TO
LOCATION
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PERMIT GRANTED
AP OVfD
INSPECTOR F BUILDINGS
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