203-209 ESSEX ST - BPA 2010-51 The Commonwealth of Massachusetts
Department of Public Safety
.\tassachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
r SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
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No. and Street Cih /Town 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 Alteration X I 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 Engineering Peer Review required? 1 Yes ❑ No ❑
Brief Description of Proposed Work: g UtW i^f OWS ,Qpp .r,�
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): 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 ❑ A-2r ❑ A-2nc ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High 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-10 R-2 ❑ R-3❑ R-4 ❑
S: Storage Sl ❑ S-2 ❑ U: Utility❑ 1 Special Use ❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ 1 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:
Public Check if outside Flood Zone ❑ Indicate municipal
A trench will not be Licensed Disposal Site❑
s
Private ❑ or indentifv Zone: or on site sc requiredvor trench or pecil v:s[em ❑ hermit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I li,urtn, iow Pro,"'!
Nnt Applicable ❑ is titructure�,ithin airport apprnach area:' Is their review completed?
111 C nnacnt lu Build enclosed ❑ Yes❑ or No ❑ Yes❑ .Air ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cede: CIe Gruup(s): Tvpe of Construction: Occupant Load per Fluor:
Does the building;contain an Sprinkler System?: Special Stipulations: �/
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Addryessot Property Owner
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Name(Print) 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
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to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed space and/or nut under Construction Control then check here O and skip Section 10,1)
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
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Comp an 2y NamI�he:
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Name of Person Responsible fur Construction License No. and Type if Ap licable
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Street Address C y/Town State Zip
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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 tJ,ie issuance of the building permit.
Is a signed Affidavit submitted with this application" No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor p
and Materials) Total Construction Cost(from Item 6)_$ o/ GU
1. Building $ / //0 0 0 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ 4000 appropriate municipal factor)_$
3. Plumbing s 'e- /
4. Mechanical (HVAC) $ e— Note: Minimum fee=$ contact municipality)
5. Mechanical (Other) $ ler Enclose check payable to ,0 3
6.Total Cost $ (contact municipality)and write check number here ' p
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.
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['lease print and >Ign n�vne^ Title Tell eph� e No, D to
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Street Address City/T cn State
Municipal Inspector to fill out this section upon application approval: 'r'r'✓
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