49 ESSEX ST - BUILDING INSPECTION r
S
The Commonwealth of Massachusetts
\'. t Department of Public Safety
\la..avhusvii,State Building Code l%80 C NIR)Svventh Edition
City of Salem
1 1 Building Permit Application for any Building other than a 1-or 2-Family Dwellin
(rhis Section For Official Use Only)
d ulding Prrmil Number: .Date Applied: Building Inspector:
SECTION 1: LOCATION►Please indicate Block a and Lot a for locations for which a street address is not available)
qSSofK SU-Lff kt /"A o ig1
.No. and Street C it)•/Town Zip Caklr Name ut Building(it applicable)
` SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Exh Ling Building Repair Alterattun 13 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
ChangeofUse ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents bring supplied as part of this permit application? Yes ❑ No
Ix an Independent Structural Engineering Peer Review reyuired?,f,L{'01KoE Fb� tWT�Z- Yes ❑ No 0
Brief Description of Proposed Work: �/V$ T�-2 3 {'/DDA-FA✓ .)O y6J-F HV 1�G- -W7 N/ Age
� 72N9 Sc .lE W m' S r >/.�
N /✓ G 0- WK
_ /c R177av fTz Lf T SST L /oD
A> dj 9�ve7ia 1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BOIL ING UNDERGOING RENOVATION,ADDMON,O
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Hazard
Index Proposed Use Hazard
Index r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flucim/Stories(include basement levels)Qc.Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 3:USE GROUP(Check as appIlcable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 0. Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ Hi High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I.1 ❑ 1-2❑ 1-3❑ 1.4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S: Stora e S I Cl 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: '
SECTION 6:CONSTRUCTION TYPE(Check as ap Ileable►
IA O IB ❑ IIA O lie ❑ IIIA ❑ IIIB O 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 rennif: Debris Removal:
Public❑ CChawk tt Out,tale 19,n,d Luna•❑ Indierte municipal ❑ A trench will not be Licensed Di>p,,..d Site ❑
required❑or trench Or.pea•tfc:
I'n rate❑ ur mJanhh Lune: ur un cite*c.trm ❑ permit i.enclu.rai ❑ -
Railroad right-of-way: Hazards to Air.Navigation: \l.\ (n.r„r„ ( ,nnn..un I<,u,,. t•n.r.•:
\,,I \ppltc.dde❑ L Fuuctun•,anhut aupurt appn,ach crest' I.thvtr rea ie,c cnntpleted'
a't' anent h,Ihul.l cncL,rd ❑ l a•.❑ ur.\u❑ \'r.❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I ,fuirn.4 C.Ov. L,e l:n,upF.c rt pe ut Cun.trucuun: lkcupant Lnad err l lour
I ,-.ihv hwkhog cnntem,t n<pnnk ler m,tem` Tpa•a'ml>Igtulatn,n.:
SECTION 9: PROPERTY OWNER AUTHORIZATIONPrOpt-r r ,,
N.utre/ ty Owner
Name(Print) .No. ,end Street C it\-/ Town ZGp
1'rolq•rH• the nrr Contact Information:
Tilly Telephone No. (business) Telephone No. (cell) a-mall address
1(a hcablr the pro rIr a�e nrr hereby a�yhomers
Name sirart Addrasr City/Town State Zip
to acf on the *ro•erw owner's behalf, m all matters relaucr w work authorized by this buildingpermrt a , lication.
SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
(If building is less than 34,Lw cu.It.of encki. -j Space and/or nut under ComYnrAion Contrut then check hen Gand.,lup Sectwn 10 1)
10.1 Registered Professional Responsible for Construction Control
Y4h�m
c 5 4 7fr.SaR--a l7 4 STc 9 ewc,l eo \�fic1�'I} , )0 a0 S G
Name(Registrant) T lephune No. e-mail address Registration Number
C' IgiI ,),. Sri -)kwt,- "14 OlS7o o`Fa(O
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cumpany Name: ?
.\uhr C9 errr� C S !�d IJ
Nam of Persu(t Responsible for Construction License No. and Type if Applicable p
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION I SISATION INSURANCE AMDAVIT(M.G.L.c. 152 25C(6))
A Workers'Cumpensation 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 0
SECTION 1L•CONSTRUC770N COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=f�_
1. Building S Building Permit Fee.Total Construction Cost x (Insert here
2. Electrical f appropriate municipal factor).f 3 2S_
3. Plumbingf
4. Mechanical (HVAC) f Note:Minimum fee.f (contact municipality)
5. Mechanical (Other) f Enclose check payable to
6. Total Curt S (contact munici alit )and write check number here
SECTION 13:SIGNATURE Of BUILDING PERMIT APPLICANT
Itv entering my name below, I hereby atlrst under the pains and penalties of perjury that all of the information conhuned in this
applicaton is true and accurate to the best of my knowledge and understanding.
Sorg IlIe 9(7y
I'le. .e print,end sign name - r� Title Telephone.No. Date
a- tqw"-tl'f S-4- st;1ts h INA CcIR70
�Irvel Addre, C'in i Town Mate !ap
Municipal Inspector to fill out this section upon application approval:
'.Ime ).ne