5 GOOD CIR - BUILDING INSPECTION (2) ti < 1
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The Commonwealth of Massac4}1se��
Department of Public Safety ' .
I Massachusetts State Building Code(780 C�1�R�
Building Permit Application for any Building other than a O AWFImPf Qmv@long
' (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK- .
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ 1 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? Yes ❑ No ❑
Brief Description of Proposed Work:
Gt i G
SECTION 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 CNIR 34) ❑
Existing Use Group(s): Proposed UseGroup(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)8r 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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1. ❑ F2❑ H: High Hazard H-1 ❑ 1-1-2❑ H-3 ❑ 1-1-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 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 ❑ ILIA ❑ IIIB ❑ 1 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %1,A Historic Cnmmitishn Rev oxv Prgcesv:
Not Applicable❑ Is Shvcture within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ 1'es ❑ or No❑ Yes ❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): 'type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
K U374I G/Z# 1 5^G000l Ct'Id,, . fwzclq_ 0/9?o
Name(Print) No, and Street City/Town Zip
Property Owner Contact Information:
J
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 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 not 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
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:IVORKFRS'CONIPENS A1'ION INSURANCE.rY T[DAVIT M.G.L,c.152.§ 25C 6
A bVorkers'Compensation Insurance Affidavit from the NIA 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❑ No ❑
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 (HVt\C) $ Note: Minimum fee=$ (contact munici �, 'ty)
5.Mechanical Other) S Enclose check payable to
6.Total Cost (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 tie and accurate to the best of my knowledge and understanding.
Please p unt and sign am Title 'Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: v lrr"� / Lf la d
Name Date
m
3 t CITY OF SALEM, MASSAGIUSE TTS
BUILDING DBPAR77,1ENr
r� 120 WASFIINGTON STREET,3nFLOOR
TEL. (978)745-9595
KIIvIBERLEYDRISCOLL FAX(978)740-9846
MAYOR THows ST.PIERRE
DIRECTOROPPUBLICPROPERTY/BUILDINGCD Il&HSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date !v�1
Job Location / (, pO r7f �'� C
Home Owner Address__
Present Mailing Address
The current exemption of"Homeowners"was extended to'include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one=or two-family dwelling,attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable
to the Building Official,that he/she be responsible for all such work performed under the Building
Permit.
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE { o
APPROVAL OF BUILDING INSPECTOR v/