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15-17 FORRESTER ST - BUILDING INSPECTION � � - . � � ��'�,�.od .�- , - _� , � �. ' The Commonwealth of Massachusetts � �' i`i � Department of Public Safely � � �`„� . � \la.s�chux•u..ti�.��r tluddm�;l'odr 1:13�C\IR)Sr��rnth Editi�m � City o(Salem Buildin P¢rmit�A lication far an �uildin oQher than a 1- or 2-Famil Dwellin � 1 lhiw tiea�tiun Fur Ufficed U.Vr Univ) (� liuJding Prrmi� Numlxr. Datr Applir.f: Bwlding In.Fxctur: v � ECTION 1: LOCATION IPleax indlcste BIac4 M and La1p1 tor IocaUons(or which a streef addre�� is nol aysilable► � � � Q� l� \��. anJ ti�rrr� � Cih•/i�nrn Zip Gi.ir � Namr ol Budding 1��.�ppliceblr) SECTION 2:PROPOSED WORK I(Nrw Conatructwn chrck hrrr�ur chrck oll�hat apply in thr twu ruwy brluw , Exi.�in�BuildinK�" Rrpair O Altrratiun J� Additiun� Drmuliti�n O (Plranr fill uut.ind,ubmit Apprndix 1 j ChanKao(Ux [] ChanKrufOccupancy O Uthrr ❑ Sprci(y: Arc building planv nnd/ur cunvtruction ducumrnb bring�upplird a�part uf Ihiy prrmit applica�iun? Yry �' � Nu ❑ Is,�n Inde�rndrnt Strucwral Enginrrring Prrr Rrvirw rryuired7 � Yra � No B' Bri�t �t�rip�iun of Prup�+ed Wurk: .. Z � � Ors' R �'�� W� e!� Bo+C , i C e-� O�h�� — S C11' � �`� _�� _��_- - ... ����r�i� uN/T � SECI70N 3:COMPLE7E'J'HIS SECTION IF EXISTING BUILDING tiNDERGOING RENOVATION,ADDfiION,OR ` CHANGE IN US80R OCCUPANCY Check herc if an Eai�tt�6 Buildins Evaluatlon is eneloned(See 780 C R 3402.0) O � Exiyting Use Croup(s): Pruposed Use Croup(s): � Exiating Hazard Index 780 CMR 34: Proposed Harard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Exieting Proposrd No. of Fluun/Storirn(include basrmrnt levels)&Area Per Floor(sq.ft.) � Total Area�sq. ft.)and Total Height(ftJ SECi'ION l:.USE GROUP(Cheek a�a lieablq A: Aa�embl A-1 O A-2r O A-2nc 0 A-3 O�� A-4 O A-S O � B: Busines� O E: HduuHonal O F: Facto F-1 O F2 O Hs HI Haza�d H-1 � H-2 O H-3 O H•4 O H-5� t: Inatltutlonal f•1 O I•2❑ 1-3 O I-i O M: Mercantlle❑ R: ResidenNal R-lO R-2❑ R-3 O R-1 O S: Stongt SI O S2 O U: Ulilitr❑ Speelal Us�O and Ira�drvcribu brluw: Sprcial U..r: SECTION 6:CONSTRUCiION IYPE fChecic u a Ilcabl�► IA O 18 ❑ IIA O 118 0 IIIA O IIIB O IV O VA O V0 0 SECTION 7: SITE INFORMATION I nftr to 780 CNR I11.0 tor detail�on each iteml IYrter Suppl r: Flaod Zone Informatian: Sewage Dlepofal: Tre�ch Pertnit: Debris Rrmoral: I'ubl�c I$ Chcrk�I��uniJe F4Mn1 Cuna•� Indiartr munirry+,il� �\ Irrnch wdl nnt br Liren.a�l Di.Fv�.J�itr�' 1'n��.uv❑ ��r mdrntd�� Zunr: ��r�m.rtr.cdrm ❑ rr��uved�'ur trenrh ��r .�•.t�i�': . . F•rrmitnenrlu�ralO R�ilro�d righhof•war: � Haurda to Air N�vigation: . �i�� I i�.�,,.n c ,�imm�.��„� I<.�u.��. I'n�,.�.•; \nl :\����Lrablv� I.�Irurlun��cilhut.nr��urt aF•F•rnaah erre.' I.Ihc�r rr�ii•�c CmnFdcle�l.' ,�rl�„n.ontl�� Hwl.lrn:l,�vJ � 1c.0 ��rX��� Yr>❑ \n ❑ I SECf10N B:CONTE4T OF CERTIFICA fE OF pCCUPANGY I .Iiii��n ��II�,�Jr. _ l.vl�ruuF•l.c f�pr���l',m.tru.u.�n: �k.u��,inll.��.i.lpv� llnur � 14�r. ihrl�uil.6n�;.��nia�n.in<F�n�Alrr?�.livn` _ ��av'ial�h��ul.�uan.: / ��i'��,'.� � /�J' �'o .L.c P.. 7P� v�T. .) ` / .�p r� ��!? /� SECTION 9: PROPER7Y OWNER AUTHORIZATION � .�1.�-ma.�.l .\.1�1rr..�i1Pn�F,a•rt�� U�\�r� � ���hk � (�npPl�r. � C�� �\,l EV N.�mr IPnnil .Vu. end�trert l il�•/ f�nvn G�+ 1'n�perH' lh�nr�l�unta.� Inlurma��un: — — �_ fs2 l" 5�� Tillr Trlrphunr Nu. Ibwmr..l Trlrphunr Nu. Icrlll r-mad a.ldra�. I!e , .hr.i ihr�au�•rrh�u�.�nrr hrrrt+v.��U uncr+ �q� `-�'�r. `�� �? t��a�- Qt•. �,� M.� �� , .\.imr Saa�r� Addrr.v Citv/Tu�vn Sl.ur Lip . � tu act nn �he �ra trlv��wnrr'.brhalf. in ell m.wrrr r.loti�ro w w��rk.udhuricr.l bv thi.buddin �rrmrt a > >Itraliun. i SECTION 10:CONSTRUCTION CONTROI IPleau fill ou!AppeadiY 21 lll buJdin is la�x Uun.15.WU:u.n.�rf.�n.i�wJ s �n'e and/ur nut umivr l'oa.ln�ition C.�nlnif Ihvn chet4 hert O and.W Sit�hun IU.1! 10.1 Re istered Profes�ional Res on�ibl�tor Cons�n+ction Contml N.imr 1Rrgis�renl) Trlrphunr Nu. rmail.iddrrxs Rrgislration Numbrr 5trrrl Addrrs.y Cily/Tuwn 56�te Zip Di�Npline Expiraliun Datr < lO.S Ceneral Contnctor M �\t`l �YI `i�?�. m�� •�\ 1�1ny�bo � ' Cum an Name• � � �-1 �C �^-�'f " r \ �IST J u uJ � Na`Zr n r.��mni� Ir(��CunYlructiun � O�' Licnnse No. and Type it A{�plicable�q � ��-+� �� � h 2 Streel Addrrss City/Town State Zip �-�- lg�Z __ �trQCZ\�S�i ca �sn.cn�l � Trlr hone No.(businexv) Tele hone No. cell � �mail addrcss . SECITON 11:W V (M.G.4 a 192 23C(6)) A Workrn'Cumpenyatio�Insunnce Af(idavit from the MA Department of Induetrial Accidenb muet be mmpletrd and ,ubmittrd with this applieatfon. Failuro to provide this a(fidavit will result in the denial of the iseuanee of the building permit. is a si ned A(fidavit eubmitted with thie a licationT Ye��f No O � SECITON li CONSTRUCT(ON COSTS AND PERMIT FEE Item Estlmated Custr. (L.abor � . . and Materials) Tatal Construction Cost(from Item 6)=E � � l. Buildin S � (7C70 Building Permi!Fee�Total Construction Cust x_(Insert here 2. Electrieal f O approprute municipal factor)=f . 3. Plumbin � . f d � J.-Mrchanical (HVAC) f Note: Minimum fee�S (contact municipality) 5. M¢chartical (Othrr) f Encl��w chrck payable to 6. Tutal G�vt f Z1 (��� (contact munici alit )and writr check numbrr hrrc SECTION 13:SICNATURE OF BUILDING PERMIT APPLICANT . Nv vntrnnK my namr brluw. 1 hrrrbV.tllrst undr�thr p.unv and pcnaitir+��f prnury that.d�uf�hr infurmatiun r�mLunrJ in thLr .ipplic.i�iun is vur and��ccurotr 1�� thr br.l ul mv knuwleat�r anJ undrr.t.indinK. : � � � '� � Co��`d�ic�tr �S's .S�J . 1f�\Z � 1'I`��r�i�,t^(i.1 •9v�11 �. � F �U'e� fitle _ ^��i•li•E�'���� I).tl� I �e�dS �r\ v �h'rcf .\.1��rC.. C�lf1'iT����n �I.tftl LIF� i �tuni.ipal Inspec�ur to fill au��his section upan+pplic�lion �pprov�l: �i[�L \,�mr � I)�tr � � CITY OF S.�LE.�t, I�L�SS.�CHL"SE"I'I'S et:aa�G Des.�Rr+�t • I'0 W.��r+avcroN S1usT. Y FtooR h1, (97� 1�S�9S9S F.�x(71511�49b1� ' K1>mEJ�-EY D�i3C011 7?10NAlST.Pltilli NAYOt Diar,c�ra t oI R euc vw►�arr/K anaC coaanssta�es Wurkers' Comptnsatlo� �ntursnt���Rld��iN Du1ld�ra/Con�►uto�lEleetrielraalPlrmAees a � Ile Inn m � vame�NYne.+.ay.uana.�nJ•��ulY• q °1` � ,WJrc�r ,--� � �S� - c��y�sti«z�� '�� , �"l�- G\,�17�3 rrw�.�: �-�e�Z .►n yer A�wyM��!CMs�tM a/M�Naa Ma+ 7�'M o/Y/o�M(n4W►�k I.0 I am�.m��wiv �. � 1 a���nnd cauAc�or ae�1 6. ❑N�r coRfauctia� ,my�sle�(fWl ana/af pw-dar}• h�v�hiee/�1r ai►eoiYacew IiatNm�h�ataelW�haR= 7. �Reealdin� 2.�1 om��ob po�ms�r prurn 7'1�w�somnsas hrv� t. ��]nnoliMo� .hi/aal A�vr no an/bye� �.a�Yln� Ar m�u a�r capsiry. �rarla�'eom�Imir�aea 9. �DaiW(n�addltio� (Ne+akm'conF inwnnc� 3. [] W�rw a e«pwMl�an/i� I O.Q Ef�caiesl r�in or additiar h,��� o�11e�s A�w noadser tfri ).Q 1 am�ho�o�r�Join�aU woAt ^li���P�P�M� t 1.Q Phunbhy iei�in a1 sddltlsa myal[[W wer�us'eanF a 1�7.11(���n/w�An�n� I 2.0 Raaf iep�ira inarrano�R9W�1� `��0� 1���' I).QO�h�t comF imurana a�i�e�.) •n,y+Mr�,r�ur arM��� *.r,r.N ar u...a.Md�r�aw+y tirr..r•c�/+.r�f id..r.. '1 hww�w���YYwi��'Y i�I1dA�1�a�JoiM rl eF�ai Ir Yi�.��e�oriw��M��i�nw il11�MY n/foriy ...� {{„+�rw�Mr.�wY�W r�awnW/+�aY�iwl.lr�JwM�J�sr 1 Ar.A���r1 drY�w�w'ce'►P�R1 i��rl� . /a��w nr�jw dY�11r�►IIlw�wwRM'c�w��Iw�ar�wa/ir q iay�rywa �Air 6 diNAhj�wl�a!b le�r�rril�s � Imurrnc�Cumpany Vamc Nnliey/w Sdf-ina Li�.M: E�cpi�io�Dan: !ub`Jiu AJ�htc Ciry/Jta�ZiOc .�eae��cep af tY wM�»•e��MaNN�yNYr d�ehn�IM WP(�MwM��r pNle����Mr�N n�IrrlM dW} F'�ilun ro w�wt cov�np y reqri�d unJw lallo�2JA of NdL a I!2 caq Ip�to�A�imyaitkn o/erimLul pn�dNp a/� ��e�p ro s i.sao.00 a�d/a anwr.ar impiaen�n�a�w�Y u dvil orn�io iu itr fans uf�STO►wO1lK ORDE�ad�Rar ,�f up ro 5270.00�Jar+�piny ih�riolua. 14 mhia�J�Atl a w�r u!ihia�sunewnl rn�r bn fw�r,rdeA�o�M 011le�of Invony��iuN,J'�M�f7lAfori�iu.ranc�cov.raprwlkalioR -- / �/�A�r�b1 �rN/y�wIM rAr priws rw1 ytwr/Na�/M/r7�A��M in�irw�dw�nril�a �v ii nw rwl:wrid :�., � � �r! P• i A. �)y✓—Lg� I O/J/i'ifI riI J��/J� /II r/W MIIN/A/A1/I//S/I II�V/1�o/iM ej rr7 w��wv�..//lrir! � C'iry ar fuvn: -- YermiN.leemtl_- —. - --- � I.w�n�.\u��ori�� Icircl���nt►: . I� iluarJ u(IIe�IIA 1. HuddlnY O.•ya��mrn1 ). ('I��lfow�CIvY !. ff�clrital l�npsetoi 1. PlumAinR ln�y�aio� - 6.U��t♦ . _ . i 1.���l�dPenan: . _ . Pflo11t17 CITY UF SALEM PUBLiC PROPRERTY �" � D��Sp�T?vI�NT 1 �rI ' . ..,MI���11 � I:Ck�.�JM�1..��Y)OtC1 �1111f1. \�.Ni11111 � 1��.1'��. I'.11: M1�1 ' �� IM� �I .�.�M f tl� '�:t-:J.4ypy ����t:'N/•. 4' C�nstruction Debri� Disposal At'fidavit (r��yuire�l liu�U dcmolitiun :��1 R'�v�liun wurk) (n accunl:uxc wi�h �he siath eJition of the Slate Duildin�CoJe. 790 CMR scc�iun I 11.3 Debris. �� �hQ P�����uns ul'MGL e 40.S 34; �yGL e is isrued wi�h Ih�condition thot the dcbris resultin�{ m �uildin�{ 1'ermit M��" ' 1 licrnxd wm't°di'F°�al foeility �deAnod by �hia wurk shall he dispoacd of in •r proper Y ! l l. S I J1)A. The debris will be Irun�pcn� bY� N� Uu uY hoular) I'ha Jcbria will be di�posed uf in : �1 �1� �, ����,\ _ . ����,�.� x� ��y � �,�� C��e�� _ �;,,w,.,,,�rr�, i��y� - .��na�urt�M�wrmi��pylicaM �I�1 � �,�. �.�..,..,,.... , , , +-. �lo..achu.cl�. - Dcp:u'�mcn� n( Nublic �:dcl� � Ru:u'd uf Buildin_ Kc_ul:ilinm and �landord� � Construction Supervisor License License: CS 52026 12r.siricted to: 1G ie� `fIMOTHY R BERRY � . � 12 LEDGEWOOD DR DANVERS, MA 01923 � o�LL si��E Expirdtion' 12/19/20,10 T:� 7� � ,.�������„�..��.��� .. � __ _ � � . . . � .�r -." ' . ' - - - - - - ' - - " " " ' - - - - -.- - - - - - - - - - - - - - - - - - - '.- - - - - � - - - - - - - - - - - - - - - -.' - " - - - - - - - - " " -. - - ' . - - - - - - - - ' - -- - - - - - - - -.- " - -.- - - - - - - ' - ' - " " . - " " " " - " - -." " " ' - - ' - - - - - - - - - - -. -. - - - - - -�- - - - - - - - - - - - - -' - ' - ' - ' - � � - - - - - - ' - ' - - - - - - - - - ' . " - " ' - - - - - -� - - - - - - - - - - ' - " - - - - - " - - - -.- - - - - - - � — — . . . , ; ; � � / � , � , , , , � , ; : , ; , � � � . , ; � - _ � , , , � , � � - _ � � . : ; � , : � � � � . . : , , , '� ; , . � � . � . , , , � . ; ; . : , . , , � - - � � _ - � , , . . . � , ; � � , ; . ' R. Rumpf & Associates, Ina � , , , , : , ' Engineering & Architecture ; , ' P.O. Box 4483 � . ' ' � 57 Wharf Street — 2G � � Salem, Massachusetts 01970-4483 , �, � , , , , X ; ---------------------------- ; , --------- ----- � � ; --- , xis mg r---'---- � ; ,, �-------- ; ; pn Deck 6elow I Roof Below � � � � up � , � � � � Roof Below N . . 1 . . .. � . � � . . . � . . . . . . . . . . ' N i . 1 ' . . � � I . . . . � . .. .. . . . . . � . . .. . . . . � � . . . . . . L . . . . . , � ; � � (978) 740-5025 , � I ' ' ' , , — ' ' ` (978) 607-0045 fax � � � � ----------------------------------- I ry cn Consultanta: , 3 � I � : ' � I p � - II � � � , L I � I � <a � I I � � `n I Existing EPDM � I ' , , �> � � � � ; I � / , W J � � I I i i ; Existing ist ` � / ; � � I � ; ' � , -i I I I , Leve l Dec k ' "' � � I I � L — ' p � lob Number: , Dn I II ' ; / , Dn I I Existing Rail�d In E ress I I , / /', _ ��� ��—��� _ I I Path to Exising �tair I I � ; � I I I � , ; Dat« . r� -� ��/1�/_2�1� � , � � � _ I p Ref. I � j i I /� \ I � ' � � � I � ' � , ; � No. Date Revision By: j � � I � � ��xistm � — I � � � � I ; � j sath9 I _ � �J I � J � ; — ; ; �xlstlYlg � ; � i i � ; �isting ; ; Unit �2 _ , ( , , ; i � � `� L �� �x�st�ng � � i i ' Unit #3 � ; , i - ; I � Exisiting �. ', Kitchen I � i / ; j � I Corridor � Existing j I , — , � i � � � � Bath � ' , , I � ; ; � — � I I x J I � � , � O O I I i i Rer. � p � I i i ; , up i ' , ; - � � � � ' ; � � ii . . , , , , , , � i i , . ; ; ' _ , , , , .:. � � � i j I Ga I � j � ; ; �1�1J up i ' � � u � ; , / � ' � I � I I i � ' ' , ' , _'__ . i i o o � Existing � i � . ' --- — , I � # � I , L ' , ____ i � O O I l�Yllt � ( � j ; ° --- � Project: � I � I � ' ; , � � � `� �; Third �loor , i �xistin � � � � � ; �: � i #� r i , ' � , � � �gr�ss _ Plan ' � (UYllt I i g Existm I : ; , _. � ' � �xisitn Closet � �iving Room � j :° ; ; o , ,;3�a D Y:ow ��,�..y� ,�__ ; i Ewsting I � � I I � , , � _�< � �� � � . . � I Kitchen I � � . . l� _ J � � � � � � I � . . � . . c � � . � � � . Cs L Of ul�.Fea�FF:.."iati. . : "1+� I18-'1^.`*�ll. 1Ct1'JII. . . � � � . ' r . � . . . I � I . .. � � . .� I I . . . . . . . . . � , . � � � . . . � I . . . . � ' . . F^�JI � . 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Rumpf & Associates, Ina Engineering & Architecture � " " " " " " ' " ' _ ' _ " " " " " " " " " ' " " '." " " " ' " " " " " " " " ' " " " " " " " " " " " " " " " " " " " " '. " " ' ' " " " ' ' � " " " " " " " " " " " " " " " " ' " " ' " " _ " " " " " " " " ' " ' " " " ' � " ' " " _ " " " " " " _ " " " " - - - • - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - , P.O. Box 4483 ; - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , ; , ' S7WharfStreet - 2G , � � . Salem, Massachusetts 01970-4483 ; �, � , ; ; X � xis ing ----------------- , , � r---------------------- � , � �---------------------= ' F-- � � � Deck Below I I ; � � � ; , � Dn � � ���� / � � / � Roof Below � � � � I . I Roo�' Below � / / / � � � � � � � �� , ; � � � � ; ; � %/� � � ' �, (978) 740-5025 . . � � ' . . 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I � ; � , , j � ��j� � — � — — � � � � � � � � � �/ �,�' � � � � I Install New Door Only w/ I � ; / � / � � � ^ � I � Passage Nardware. i � � I � � ' , / ;� ��� � � j � Existing Existing � j � � � ��i/��,%��j �'►.�y� � �� : I � � Bedroom Bedroom � � ' , � ' ' , / � , � I � � � I ' , ; / / �/j � � I � � � � � � � I ���,, �/ /� �� � ��/ � : i i � �� i i ��, ; j �j,;�i,� ;,;�j � � � ; / � Third Floor lan � � � � i i � � � � � � i ; , ,� ,�; � i/�/i,� �/ / � " �� , � Patial 5�cond �loor Plan i � � � � � � � � � ii : � ��' � � ��// ��;��%'�- �� � � �' Partial �irst �loor Plan i � � � i, � , �%���i ,� / ' /�'� �� ' ' l Existin Conditions) � � � � � � �� � � � � '� % ' ' ' � �� /;' g � � L� � �J I � , � � � ' �� � �� ��� �� � � � , , ; , �,/ % ,�/ / / „ � �� , ; , ,�/;��j � '/ � scste- i i� ��� � Star �plow; , ' � � � � �ii � � � � ii� ' � '/ i , i � ' : , ; , ; / �/� �s +�ot�ol , � ----------- � � ---- � --- � , , i ----------- � _---__---- � ' � ---- ' -- ; ; _J � . 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