DERBY ST - BUILDING JACKET (3) a
1
;l ,Y The Commonwealth of Massachusetts
Department of Public Safety
��� -,,•f Vassachusetts State Building Cede(780 C\IR)ticrenth Edition
City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Bwlding Inspector:
SECTION I: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available)
, :60 i�u6adt, 7o Caotaa��zs �, --��—�i1� e� k
and Street City /Turrn Lip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
�l\J If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other X Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yew No ❑.
Is an-Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: t0
v h�!/lrf
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 Croup(s): p
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
=10
ng Proposed
No of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE CROUP(Chec
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-13 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ ❑ R-2 ❑ R-3❑ R-4 Cl
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 ❑ IIIA ❑ 1116 ❑ 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 it outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑
III i caty ❑ ur indenlifc Zonc•: ur mi site,%stem ❑ ruyuired ❑or trench nr .pecifv:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: xin lli+Inna( rc a.. f'nr•..;
\id %pPliC,IHV❑ I.ti IUCI ore Nrilhui airport appru.iCh a va' I. their re% v%, Cn111p1c0.•d'
�'r( i v)Iunt 10 BUild onC o1cd ❑ Yvs❑ ur.\o❑ 1'c•a ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA-FE OF OCCUPANCY
Fdrtnm I C jai r: L,e GnnipllC Icpv of GmslrUchon: (_)ccupant Load per Iluoe
Dne. III,building Contain ao Sprinkler Sc tvin'i Special Stipulations:
d
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Adddress of Property Owner "-
r t W ah rd
Name(Print) No.and Street
City/Town Zip
Pr 0%%ner Contact Information:
u�erty
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 as on the pro perty owner's behalf, in all matters relative hr work authorized by this buildin •i2ermitapplication.
.SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,W0 cu. it.Of rnclusLd Splice and/or nut under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Constnrction Control
-pofol,�4 O m-e, 17k YiS- /vase Z/
Name(Registrant) Telephone No. e-mail address Registration Number
�79' N/�e�ln wC S71 �Pv /ia� US&
Street Address City/To%Yn State Zip Discipline Expiration Date
10.2 General Contractor
O d 1
Company Name: � � tJ�'�5 a (�S
1 7
Name of Person Responsible for Construct: SA/ License No, and Type if Applicably
� e� /G1lD G
Street Addre s City/Town J/ // State Zip
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 No O
SECTION 12:CONSTRUCTION COSTS AND PERMI EE
Estimated Costs:(Labor
Item - and Materials) Total Construction Cost(from Item 6) _$
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ P°Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) - $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv 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. ll
Ne mint and sign name Tide Telephone No. Da
C \R7 6-c- e w /Ql c _— �� a
Klreet Address Cit%/Town /f�
State Zi q
Municipal Inspector to fill out this section upon application approval: v `
Name U. to
4
Department of Public Safety
License to Operate Amusement Devices
Mr.Eugene J.Dean,Jr. License#: MA-001-07
(603)474-5424 Issued Date: 4/20/2007
Dean&Flynn Inc., Expiration Date: 3/15/2008
Fiesta Shows
IS Pine St.,PO Box 460
Certified Maintenance Mechan6
Eugene Dean
Seabrook NH 03874
U.S.I.D. 0 Device U.S.I.D. # Device U.S. I.D. N Device
05266 Pharoah's Fury 10400 Cobra 10453 Dark Ride-Castle
0997 Slide 10439 Zipper 10455 Sea Dragon
099 Scooter 10440 Twister 10457 Skymaster
099 Merry Go Round 10441 Surfer(Tip Top) 10458 Haunted House(NM)
099 8 Tilt A Whirl 10442 Zipper 10459 Apollo
09979 Ferris Wheel 10443 Roundup 10460 Flying Bobs
09980 Turtles 10444 Cliff Hanger 10461 Dragon wagon
10016 Swinger 10445 Sea Dragon 10462 Berry Go Round
10017 Tornado 10446 Tilt-a-whirl 10463 Panda
10167 Freakout 10447 Thunderbolt 10464 Elephant
10204 Eurobungee 10448 Scooter 10465 Boomer's Circus(NM)
10394 Haunted Mansion 10449 Gondola 10466 Merry Go Round
10399 Pole Position Spinning 10450 s ) QJ 10467 Slide(NM)
Coaster '!�✓
Tuesday,July 24,2007 Commissioner of Public Sq" Page I of:
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w
Department of Public Safety
License to Operate Amusement Devices
Mr.Eugene J. Dean,Jr. License#: MA-001-07
(603)474-5424 Issued Date: 4/20/2007
Dean&Flynn Inc., Expiration Date: 3/15/2008
Fiesta Shows
Certified Maintenance Mechani
15 Pine St., PO Box 460 Eugene Dean
Seabrook NH 03874
U.S.I.D. # Device U.S.I.D. # Device U.S.I.D. #Device
10468 Tommille 10486 Umbrella Dune
10469 Earthquake 10487 Gmvitron
10470 Grient Express 10498 Dizzy Dragon
71 Baunce-SR 10489 Crery Bus
10472 Aeromax 10490 Hampton Combo
10473 Street Racer 10493 Rock Wall
10474 Rockin Tug 1000121 Bounce-CA
10477 o Round
a10478 Raiders(NM)
N.
10479 Crary Btp
10480 Convoy
10482 Slide(NM) '
10483 Go-Gazor
Tuesday,July 24,2007 Commissioner of ftblic Safety Page 2 of:
EITrOF
PUBLIC PROPERTY
DEPARTMENT
to\eWjL&v n...-.v
�l arae 130 WAsaw w bntw
SMbk yASiAQM:LM 01970
APPLICATION FOR THE REPAIR. RENOYAnoN_ coNsTRucTioN.
DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUjMG
1.0 SITE INFORMATION
Location Name: FkeS ct_, ,S Ao 41,5 3umng:
Property Address:-----
- --
Properly Is located In a;dwiservation Arse YM Hhdorio District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land r _
Nam: Fe.sTcc-
Addraw, /0 0, 4ox 4 6 o
se"troe K mot//V
Al,
Telephone: (Z ,3 47 — ,2jt
3.0 COMPLETE THIS SECTION FOR WORK IN PTISIJNLi BUILDINGS ONLY
Addition Existing
C
Renovation Number of Stolilds Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation �:F
of existing building Now
add Description of Proposed Work:
Uc,T t 9 - 3 )i )-00/7 For Ma-jots ydllvuew, cc i/e•,p7 a,T
��3 Dei6y ST, Fob '�mvscn7e�1 .Q;c��5. / r1 �c� PS
-- —- ---Mail Permit to: — - - - .--
I� -
What is the Current use of�,�the Building?
Material of Building?
i!� r It dwelling.tow many units?
r
Will the Building Conform to Law? Asbestos? -
Archited's Name
Address and Phone l ) -
Mad+anic's Name
Address and Phone
Cons�ctim Supervisors Ucense 0 HIC Registratbn N
Estimated Cost of Projed Permit Fee Calcine M
permit Fee= Estimated Cost X 57/111000 Residential
Estimated cost x$11/$1000Cormmerclat-------- - -An Additional $5.00 Is added as an
Administrable duvg&
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building P wro o build to the above stag ed
specifications. Signed under penalty of perjury /l\
ate
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