6 DEVEREAUX ST - BUILDING PERMIT APP JACKET t a �
3a -y The Commonwealth of Massachusetts
ly r Department of Public Safely
%t.u.rldt u,eit,S1.1ly Budding Code(.80 C NIR)w•t'en I Edl l ton
City of Salem
A Building Permit Application for any Building other than a I or 2-Family Dwelling
`"t 1 rho�c•a'bun For Ulflcial Use Unlvl
Budding Vrnmt Numbrc Daly Applral: Budding Insprctu'
SECTION 1: LOCATION IPlease indicate Blocks and Lots for locations for which a street address is not available)
1
No.and Strut 1e •it% /Town Zip Code Name of Building (a oppl able)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
-----— pbuilding
ing —Rrpaire ❑ Change of Occupancy ❑ Ottler Specify:plans and/ur construction documents being suppliedas p. rtof this permitappiicaltun? Yes ❑ No ❑
dent Structural Engineering Peter Review required? Yes ❑ No ❑ion of Pruposcd 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) Cl
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Nu.of Flours/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-I ❑ F2❑ H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑
5: Storage 5-I ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: _
SECTION 6:CONSTRUCTION TYPE(Check as Applicable),
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ IIIS ❑ 1 IV Cl VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 Cb1R 111.0 for details on each item)
Waler Supply: I Flood Zone Information: Sewage Disposal: french Permit:
' Debris Removals
Public❑ Check rl oul.raly Ile+ d Luna•❑ lnJlc.rte mums q.•tl❑ \ trench will Oat be Lrccmrd Unpt�.rl site ❑
rctpured ❑or trench •ter 'f`catc.
I'n caty❑ or rndcn blc Zane: r�r rm .dr�c.trm ❑
i — permit.,cndu.rJ ❑
I Railroad right-of-way: Hazards to Air Navigation \1It 1h.h•n, 1 ft 10 111 1 N ,„ •, •--
\nl \ppha.d`IcD I,sl rn is l it r v to r lhm it pon ap)•nraih.ve.t` I. Ihcn ret Teo o-mld.IrJ' i
. r ln,anl lu llaul.l Cl I lc.❑ ur\uD low❑ \•r ❑
—�
s EcTION 8:CONTENT OF CERTIFicA fE OF OCCUPANCY
i I .Llnn .,l ldc ___ L•c l.nvrfv-1 _ (a pc q t- m-Ini:linn ___ l'iiuFvnl l ••.rtl f'cr lL.,., '
16•r:ihr bud•Lnq. nn.rm.tn �f`nnklrr?t.lcm `prowl<nf`uauun� __r_ ._.-_.__.--___— �
q 3 fuQw sq l•Caes
F
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SECTION 9: PRO ERTY OWNER AUTHORIZATION
V.imr.i +d Address of I'n,p r e O err A
Loa
rmU \'o.surd sl eat bill , rnsvn lit+
lhs see (-.mt.trl Inlurm.ulunrelephoneNo. (busmesx) relephune.No. (cell) e-mailly. the pn+perlc sm nvr hereby.orlhonzesName StreetAddrens Cav/Town stale Lipe +ru •ert% +nv rive',behalf, mall matters relati%e w workauthnnzxd by this bulldm + rrnnta + +hcatwn
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
ldm is Ise.+Ihan li,llU cu.ff.ul rnduderC. utructwn Conlrul then check here Oame.Ar .h•Jnu+ to II
Registered Professional Responsible for Construction Control
Regis—f , II Orprione u. a-mat a ress egistmliun Numbr
Sheet Address City/Town state Lip Discipline Expiration Dale
10.2 Central Contractor
2 KJ 0 r
Com Name: -
` - / SAS 75 Y( s C
Name of Prrssm Respr+miblr r r Construction Lice o. and T pe if Applicable
Street Address City/Town State Zi
IL7� 71 Ry�•6 p
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION QVSURANCE AFFIDAVrr(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 PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$
I. Building f Building Permit Fee=Total Construction Cost x
f —(Insert here
2. Electrical appropriate municipal factor)=f
3. Plumbing f
J. Mechanical (H VAC) f Note:Minimum fee=f (cpnt�pr(unci ali )
S. Mechanical (Other) f J.�
Enclose check payable to
6. Total Cost f D (conlact munici alit ).tnd write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
lie entering my name below• I herebv attest under the pgmsand penalties of pequry that all of the inform
ati in o,n talnrd in Ihl9
.rpplicntion is Inie and accurate I.,the best of my kno.vledgeand unders6mding.
I'I e.nc pnml m1.1 . n n.u�y( to ..— —_— —
�tirrl \J.I n•.. -lL—, ( rt1: Gn+n tiL le .if.
%lunicipal 11"pectur to till out this section upon application approval:
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