51 HANCOCK ST - BUILDING INSPECTION t i
The Commonwealth of Massachusetts
1„ Department of Public Safety b JUL 13 A la- 3
Massachusetts State Building Code(780 C
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:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Va Salem (34`1
No.and Street City/Town Zip Code Name of Building(if applicable)
! SECTION 2:PROPOSED WORK
Edition of MA State Code used If Ne Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration Addition❑ 1 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 Pro sed Work:
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 CMR 34) ❑ -
Existing Use Group(s): Proposed Use Group(s):
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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O IB O IIA ❑ IIB ❑ IIIA O IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION j
Name and Address of Property Owner I r '
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Name(print) No.and Street City/Town Zip
Property Owner Cbntact Informationn://�'
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
IAA Sa4uk( s a} Ip LIMA ()I9" 0
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authc 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
10.1ii Registered Professional Responsible for Construction Control
VIh�,aD kfr-2pY&7_—f 9 d�"U� v
m Re r Telep�ow No. e-mail address Regi n amber
I SaPI� � 17C> ��
treet Address City/Town State Zip Discipline Exprati Date
10.2 General Contractor
Na
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Name of Person Re ponsible or Construct License No. and Type if Ap Ecable
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Street Addres City/Town State Zip
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Tele hone 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❑ 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 (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ 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,I hereby attest under the pains d penalties of perjury that all of the information contained in this
application is true and accurate to the bes kn wled and understanding.
Please prh aOnd�s' natr�� Title Telephone No. Da e ?/
J J
Street Xd7dress City/Town // State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
6/24/16
To whom it may concern,
1, PEho r a 4 A Small consent to the second floor condo at 51
Hancock street, Salem MA 01970 front porch inner and outer doors being replaced. The owner
and occupant Grace Taylor will be in charge of all costs and removal of garbage and debris from
the removal and addition of the new doors.
Sincerely,,
X �i2 ay Q• �
6/24/16
To whom it may concern, t�
1, Ka leli I SW t onsent to the second floor condo at 51
Hancock street, Salem MA 01970 front porch inner and outer doors being replaced. The owner
and occupant Grace Taylor will be in charge of all costs and removal of garbage and debris from
the-removal and addition of the new-doors. -
Sincerely,