25 EDEN ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Department of Public Safety
•.-,.•� \tassachuscus State Budding Code 1780 CMK)Seernth Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available)
No.and Street City /Touvn 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 ❑ Repair❑ 1 Alterations 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 ❑ No ❑
Is an Independent Structural Engineerin ,Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: /.JI�a �nAfS :lG Ro
� 2
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): r
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 ❑ - A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ S-2 Cl U: Utility❑ -Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ I1110 ILIA ❑ IIIB ❑ IV Cl I 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: .
PP Y'
Public ❑ Check if outside Flood Zone❑ Indicate municipal ❑ '\ trench will not be Licensed Disposal Site❑
required ❑or trench ur.peclh:
I'n rate❑ ur indcnlily Zone: or un site system ❑ ),remit is enclosed ❑
Railroad right-of-way: Hazards to Air.Navigation: �I:\ I li.t.•rir t •,nuni..i��n It.•.6.� l'nn....:
\nt Applicably❑ I.Structure��nhui airport apt+ruadi area' Is their eel tv%% cnmplete it
„r( �m.cnt to Budd endowd ❑ 1'es❑ ur No❑ Ye ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I[dnnm ul (-011e: __ L.v group(.): it prof Cnnstruchon: Ckaipant l..ad per Flour
Urn•. the budding gmtam an Sprinkler Sl stem.': Special Stipulations:
r
SECTION 9: PROPERTY OWNER AUTHORIZATION ;
N e and Address of Pnrperty Owner
Name(Print) No.and Street City/Town Zip
Properly Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mad address
If applicable, the(+ropers% owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the properly owner',behalf, in all matters relative to work authorized by this building permit a > >lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is loss than 35,M)cu. it.of endosad s pace and/or not under Construction Contrul then check here O and skip Section IU.0
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
10.2General Contractor A �/•' G�
24�
C my Name:
Na r of Pe son Reslxmsiblr fur Cunstntctiun License No. and Type if Ap licable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 O No O
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 $ appropriate munl ipal factor)=$ - .
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee= (contact municipality)
x 5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (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.
C YIf t3 �e n /( ti 76- ZlS fo f�
Pleaac print and sign name - Title Telephone.No. Date
<tre •t :\ddre ' City/Town State Zip
� �
Municipal Inspector to fill out this section upon application approval: /v
Name ate