21 ESSEX ST - BUILDING JACKET -The Commonwealth bf'M'a§Sachusettg.`•.";, . -
Department of Public Safety
MasSaChUSCUS State Building Code(780 CMR)Seventh Edition
't". -eity'ofsale-rn" " '�71 1'.0-'
Building Permit Appl'ication for any Building other than a I- or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
OU XiC_f ew a - " A. 0 e*7-,-
No.and Street Ctt,v /Town Zip Code Name of Building (if applicable)
SECTION 2: PROPOSED WORK
If New-Construction check here 0 or checkall"that apply.in the two iows below 14
Existing
IZ,p,ir)ib I Alteration 0 1 Addition 0_ ,Demolition q (Please.fitl out and submit Appendix 1)
Change of Use 0 Change Of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 9j,-
Is an Independent Structural Engineering Peer Review required? Yes 0 No Qi
Brief Description Proposed Work:
SECTIONOMIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,0 I I 3:COMPLETE.PLETE THIS-1 I ' CHANGi &USE OR OCCUPANCY_'
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 13
Existing Use Group(s): — I Proposed Use Group(s):
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 0 A-2r 0 A-2nc 0 A-3 0 A4 0 A-5 0 1 B: Business 0 'E-., Educational 0
F: Facto a F-I 0 F2 0 �. Hi It Hazard H-1 0 H-2 13 H-3 0 H-4 0 H-5 0
�j
1: Institutional 1-1 0 1-2 0 1-3 0 1-4 0 M: Mercantile 0 R: Residential R-10 -R-4�W R-3 0 R-4 0
S: Storage S-1 0 S-20 U: utility 0 Special Use,O and please describe below: 6P
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA 0 LB 0 IIA 13 IIB 0 IIIA 13 IIIB 0 1 IVO JVAO VB
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Debris Removal;
I Sj�rage Di Disposal:
Water UPP Flood Zone Information: s Trench Pirrinit:
PLI[bli'V Check 11`01,itsideFlood Zonee, Inclicatenumicipa 11 A trench I ench will be Licensed Disposal Site
I'mmeD :ilrincicntifc Zone or on site sN stem' 10 required�Ve"1)X"trench or�pecif.%'.
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: \1A I li,tom ( 0 11111111011 K1'1 j111 Porn...:
-,Not Applicable k StILICtIlle �\ I., their review completed'
ol6'-11' ecnt to Build enclosed 0 - t I I Ye, Yes 0 NO 0 P/P
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
17111tiOu of Code:— L e GIOUP(S): _ Tv pe of Construction: — Occupant Load per Floor:
I)OCI the building C011t,1111 an Sprinkler SN stem?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name ed Address of Pruperl_v Owner e+
Name ( rint4l 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
:7
Name Street Address ' City/Town State Zip
to act on the pro pertc owner's behalf, in all matters relative to work authorized by this building permit a p plica tion.
SECTION 10:CONSTRUCTION,CONTROL(['](ease fill out_Appendix 2) •,t 1._�...-.
(If building is less than 35,000 cu.ft.of enclosed space❑nd/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
75V11
Name e)js�tra.�nt�)� Telep�h`on•e/No. e-mail address /��� Registration Number
L �'/ .rL Utz -ej&- �Q G7o !RI/d/,/
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Narn�e�
aq
Name o Person Rgs9onsible fiir`.Cunstruction L•ice`kse No.-and Type if Applicable
Street A res City/Town 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor !'•�,
and Materials) Total Construction Cost(from Item 6) _$ cam/ r+
1. Building $ A Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical A) 44 $ appropriate municipal factor)=$
3. Plumbing 4/ $
4. Mechanical (HVAC), $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) oza $ Enclose check payable to
6.Total Cost $ & (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering<fny 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.
ter/` L l9 a dG✓/t++t� ,Z 3��1
['lease print. nd .i ,i name Title Telephone No. ; Date
x lam- •
tiUeet Address Cih/Town State i�
-7
Municipe`I Inspector to fill out this section upon application approval:
Z�6
Name Date
t'
s>
CITY OF SAL&N4 1 XSSACHUSEM
• BUEMNIG DEPARTMENT
130 WASHINGTON STREET, 3° FLOOR
Ttt (978) 745-9595
FAx(978) 740-9846
KI BERLEY DRISCOLL
MAYOR THomAs ST.PrEm �a
DIRECTOR OF PuBLLC PROPERTY/BumniNG co%m ISSIONER
APPLICATION FOR THE CONSTRUCTION;REPAIR;RENOVATION CHANGE IN USE OR
OCCUPANCY,OR DENAOuITION OF ANY®uiLDwe OR STRUCTURE
Thdt1 3ecdon for Offldd Use Any
µ Dates;_ 0 l
Bslllding" I .
Es". . ' ' :ftw` start End:
Commentic
1.0 SITE INFORMATION
Location Name. Building:
Property Address: 210 Ezq 6; . Sx jeffl, M
Mapffilkxk LaYParcok
JWORWTION
L1 Owner of Land
Name: Sq "✓2 &zv4s
Address: 210 E55eX S+,
Sa� AA
Tee 9 8 95-5555
2 2 Owner or Iseses of building or stmeftm
Name: SaWn Five Sa ; Bank
210 Es5a S},
Salen9 MA
Telephone: 7 7y3-SS S
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name:
Address:
Agency Project Number.
Project Manager Name: T eC
4.0 PROFESSIONAL DESIGN SERVICES-.
4.1 Registered Architect:,
Name: Towne, — bKL As5zWes Seal and Signaturq=
Address: 2 Wes+ St SUi+e -(t
Wgmovt-h, MA 02190
.,. . . _._ 331=85 Fare L1 33 o0 6 51
4,2 Registered ProfesskmW OM Ineers: (Use adMWWit and attach to
Seal and S
Name:
Addle 187 A r st
C�eor�e�o�I�M� �833
Telephone: qTg 352-65C-0 Fax 9� SZ- 3
.-A OResporisibility
Nww and
Address:
Telephone: Fax
Area of Responsibility:
Name: Seal and Signature `
Address:
Telephone: Fax:
Area of responsibility:
J
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C 112 SECTION 81 R EXEMPTIONS
(See note below)
Contractor � � "
Name: jc-ommodore
Address: 13o I vgorj Ave
MA o2466
Area of responsibility:
'Llcetise Number." ,
Date of Expiratim
Telephone: Fax:=
Contractor
Nairtet .
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:
Contractor
Name:
Address:
Area of responsibility:
Oate of Expiration:
License Number
Telephone: Fax:,
Note: For portions of work utilizing exemptions of MGL c. 112 3.81R complete the section above.
Use additional sheets if necessary and attach to application.
,r
6.0 PROFESSIONAL CONSTRUCTION SERVICES:
6.1 General Contractor OfL
Address: 130 Numfod Ave.
N�vb�, M� 02y6C
Telephone: 617 61�- (xj Fax: 917 9 -
Responsible in Charge of Construction:
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item as Applicable
7.1 Plans (Note 1 this page) Submi Incomplete Not R@guired `.
7.1.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.6 Fire Alarm
7.1.6 HVAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note i Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
NuiAber of stories Below
Total r: • i • ! ring Area ' ..ate
above Grade
Total Building Area Below
. r
Brief DescAption of Proposed Work,
® _ ® ® ®moo®®IS
MINNIMMINK
a ■ NINNIES
9.0 CONSTRUCTION COSTS (See 7110 CMR Appendix Q
Total Construction Cost Bu7Ps;ffmitee Check Number
060016W 12385
10.0 AUTHORizAT1ON OF STATE AGENCY FOR ASSENT TO APPLY FOR BUILDING
P (when applicable)
on behalf of the State
Agency or Authority, hereby authorize, aPPht
for the building permit for project number,
Signature Date
11.0 SIGNATURE OF Su1Lome PERMIT APPLICANT
Name
Signature Date
12. Certificate of Occupancy required on completion of project? —Yes No
Inspector's Notes:
Application for Permit to:
Location
) (�fi
Permit Granted
A proved
T,ector of Bail gs
i