56-58 ESSEX ST - BUILDING PERMIT APP 4 t
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The Commonwealth of Massachusetts
i1 R I Department of Public Safety
�U"11 ^�-+d•� Nfa.,sachusctt,State Building Code(780 CMR)Sevenlh Edition
1 City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector•
SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a reef addres i e)
.S'c/a.,ti. {M, O f R O
No,and Street Cih• /Town Zip Code Name of Building vf apphca e)
SECTION 2:PROPOSED WORK
If New C instnictton 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 ❑ Change of Occupancy O Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review re/quired? Yes ❑ No ❑
Brief Description of Proposed Work: 'T
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,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
ExistingI 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 Cl 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❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
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 ❑ IIIB ❑ 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:
PP Y�
Public❑ C hock if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Di.pas.d Site❑
Private❑ or mdentifc Zone: iron.ite.v+tern ❑ required❑or trench or.pecifv:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: CIA 16t,-ri, c,nnnti—w,Itrti,•t, I'rorr..:
Not Applicoble❑ I,Stnii hoe wnhin airport approach area.' I.their re%iet% completed.'
"t l on'cnl to Budd enclosed ❑ 1'0.O or No❑ ❑
1'e.❑ \n
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdttwn of Code: L,V( loupt.l: rt eofCn,
p truduin: Cknipanl Lund per Fluor:
D,w,the budding contain in Sprinkler Sc'.teiW: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Propene Owner
Z1st� �(�lauKas CAI' S'he-fVVCP taye !?eabod-y MA 0[go
:Name(Print) No.and tilreet City/Town Zip
Property(honer Contact Information:
q7&.S5L_ _—
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 act on the ro pert%owner's behalf, in all matters relati%e to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,0(k)cu.ft.of enclosed space and/or not tinder Construction Contwl then check here O and skip Sectiun IU.1)
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
10.2 General Contractor
CGNIMG�V �tiST,�r�7r GI��
Coin�iny Name:
1( I
Na me of Person Reslxmsible for Construction License No. and Type if A licable
2ri S �YDtiE� �2 /?
Street Address City/Town State Zip
L2 G Ogg, S
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 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 municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 0 0 U (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.
'�Aulc ( tJ 617. C'ZI 034S `! i tC�
Please print, nd sign name title Telephone No. Datc
2 S S G2r
street :Address Cit)/Tilton Mate Zip
.Municipal Inspector to fill out this section upon application approval:
Name Date