83 HOWARD STREET EXT - BUILDING INSPECTION fi -\
V
,. ;►. ,, The Commonwealth of Massachusetts
Department of Public Safely
��` ...,,,✓ \lassachu>vtb Slur Budding G+dr(%8U C�IR)Sevrnlh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Famill, Dwelling
(This Section For Official Use Only)
Budding Permit Number Date Applied: Building Inspector:
SECTION 1:LOCATION IPlease indicate Block Of and Lot s for locations for which a street address is not available)
�3 1I0"A40 ri; ExfCVJ/are SQL nn a/ 970 SW-7-,a ✓
No.and Street City /Town Zip Crw1e dame of Building 01'applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ RepauQ I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ Nov
Is an Independent Structural Engineering Peer Review required? � ' Yes O No ❑
Brief Description u Proposed Work: Pre.t/rtyw e.l'6 �f�341!' L.1 u�r�t_-�•M vt- L°G�- ( [/k.4
i
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 Croup(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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional f-1 ❑ 1-2 ❑ 1-3 Cl 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S:.Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA I80 IIA ❑ 1180 1 IIIA ❑ IIIB ❑ 1 IV 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❑ C heck d outside Fbiiid Lune❑ Indicate municipal❑ A trench will not be Licensed Disfx,s.il Site❑
required ❑or trench ur.peci I.%
I'nvate❑ ticmdanulc Zone:_ or tin site se.tem❑ permit is enclosed ❑ _
1 Railroad right-of-way: Hazards to Air.Navigation: l inn....n li..i,.. l'n„•�:
\id \pplicable❑ thin airport appn arch area' Is then re+iete nnnpleird.'
•n l'nnvnt to Build ondosed ❑ 1h•s❑ ur..\'o❑ Yrs❑ \i+ ❑
j SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
1:,10i.m.tl G"J'. _..__LC.e(nivpise r+peui l..mlrucliun- r)ccupa n t le ad per flour
I)i,..the bu dd uig contam.m Sprinkler}+stem': Specal Shpulauuns
.i SECTION9: PROPERTY OWNER AUTHORIZATION
Namyea�n.l�Address of5�-Pn�perh•U�w.an�er //�I
.f YClC� ON .�4l c-+t-v �l/r Il1L l•9 0 /J/�//1/ice rr - T/f ,� of g'7 n
Name(Print) No.and Street City/Town Lip
Pruh�arly l)wnrr Cml,t nlurmaliun:
( a, + tuE aEc2 2 7 YPy6 __ CK6ReER @76M41L-caM
Title Telephone No.(business) Telephone No. (cell) a-mad address
applicable,t pnrperh owner hereby authorizes
ONI(/L.O �--OtiS o.� 1 �S �vntig r., )(-. [/w i ILeK MA
.Name Street Address CityCity/Town Stale Zip
to act on the ro+rrlc owner's behalf, m all matters relative to work authorized by this building +ermrt a+ +lication.
SECTION 10:CONSTRUCTION CONTROL 41"iease fill out Appendix 2)
(If buildin•is k s,than.}3,lhfllcu.ft.of enclosed s ace and/or not under Comtrti0on Control then check here Dandkip Section IO.q
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail addressEzipp
Registration Number
Street Address City/Town State Discipline Expiration Date
10.2 General Contractor
o NAG" fin GTt tn� C --1xLC -
Compp Name: //��
( �/ZLty L�/4'XloN)G 4A C- S b C /b 4 /
Name of?iny�in Respnsib a for Construction (� License No. and Type if Applicable
IJyn-rLrrn,
Street Address ity/Town State Zip
C�1-nor ox, s'l- t% rfo1LA-y--• I✓E9
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 o he issuance of the building permit.
Is a signed Affidavit submitted with this a lication7 Yes No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ -241,d Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ o c D appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (co municipality)
5.Mechanical (Other) s Enclose check payable to 0
6.Total Cost $ -10a (contact munici alit and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the rams and penalties of perjury that all of the information contained in this
llapplicatio(n is true and accurate to the best of my knowledge and understanding.64?)/it)6V VLIfro l 'nE4ir �a/�llf�✓.- 7 7
I11 v /
I+jeo.e prinnt.ind sign name t ritle p� "Trlephune No. Dale
(f^• Ate' p h61"�")� r v1 K D 1 v
Slrvcl .l ddress (-itc, Tutcn st le Li +
j municipal Inspector to fill out this section upon application approval:
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