203-209 ESSEX ST - BPA-08-2006 HOTEL SALEM The Commonwealth of Massachusetts
�} Department of Public Safety
i ➢G Massachuselts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
(\O SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
2t7 3 - 20`l
Vr No.:m I Street City/Town Zip Code Name of Building(if applicable) .
SECTION 2•PROPOSED WORK
n[Are
on of MA State Code used_ If New Construction check here O or check all that apply in the two rows below
I ing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition Cl (Please fill out and submit Appendix 1)
geofUse ❑ Change of Occupancy ❑ Other Cl Specify:
uilding plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Independent Structural Engineering PeerReview required? / L Yes ❑ NoDescription of Proposed Work . S2�ef-{'i 1 '1'n'�ey/o1 Apn20 /0�CTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposer!Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor.(.sq. ft.)
Total Area(sq.ft.)and Total Height(ft.) 1.2600W
SECTION S:USE GROUP(Check as a licab e)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational Cl
R Facto F-I❑ F2❑ t Hi h Hazard H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ I-2❑ [-3❑ 1-1❑ M: hfereantile❑ R: Residential R-10 R-2 O R-3❑ R4❑
S: Storage S-1 ❑ - S-2❑ U. utility❑ Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as applicable)
IA ❑ 180 IIA ❑ 11613 1 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA CI VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supp)y: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal•
Public 6F Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site Q
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
Permit is enclosed❑
Railroad rightof-wry: Hazards to Air Navigation: 41_l l,li±tnru'bmn_n�agi Neriia,I'r�x,i .:
Not Applicable❑ Is Structure within airport approach area? Is their review complchd?
or Consent to Budd enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition u(Cnde: Use Group(s): Type of Constriction:. Occupant Load per Floor:
Dlxs the building contain an Sprinkler System?: Special Stipulations: __
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
ual�( Salem okot-L-' 133 OIL �P{fy �d >�e�vbu/HQa) bo
Name(Print) No.and Street —r City/Town I Zip
Property Owner Contact Information:
Q i dicta d C ofx( 67- 31 Z- 010 - . C run z3 �- mn h I
Title Telephone No.(business) Telephone No. (cell) a-mad adpd ass
If applicable,the r
RrIG
operty owner hereby authorizes
Y
� rheS ig �P A ��f
Name Street Address City/To. t State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit apElication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
wr far' Sf FJeeAl>'tCys1YYPduC,1'Y,1Bw5 g(ei }r cow^
�tm�e(Registrant) 70u �' TL
pfep„ne No. c mailad� Olga u Registration Number
leaf [�1
J Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - )) - L
Company Name
Ar/etn BQe 0LISY7
Name of Person Responsible for Construction License No. and Type if Applicable
11 Qt--z-) )g A (n 6�o' i,�'I N �A jq /1
Street Address City/ own State Zi
VY ,?5z19 4-7 g21s $S? yGl�� hrl n orhe5, 0 I mr It' �a
Telephone No. business Telephone No. cell e-maRaddress
SECTION 11:W'ORKERS'COMPENSATION INSUR.-I NCY AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the IVIA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building S Building Permit Fee-Total Construction Cost x_(insert here
2.Electrical $ appropriate municipal factor)-$
3.Plumbing $
d. Mechanical (HVAC) $ Note;Minimum fee=$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost S o, Vn (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 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 know.edge and understanding.
/cfn go c1 Vo �C (0odiRCtII I)K-RZz/IV /z ,g
P171 print a�sign mar lh Title Teleglluyny�lo. Date
_jR GlQ z�7 7dT y �r��
Street Address City/' wn State Zip
Municipal Inspector to fill out this section upon application approval• IIA4. 1114616
Name Dale