107 LAFAYETTE STREET- BPA-10-545 The Commonwealth of Massachusetts
' Department of Public Safety
�J )I I w• Nlassachusetls Slate Building Curie(780 CMR)Srrenth Edition
I,yylllJJJ// City of Salem
Buildin Permit Application for an Buildingother than a 1-or 2-Famil D
(This Section For Official Use Only)
Building Permit Number. Date Applied: �" Building Inspector:
SECTION 1: LOCATION (Please indicate Block A and Lot 0 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
If New Construction check here❑or check ail that apply in the two rows below
Existing Building Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No PJY
Is an Independent Structural Engineering Peer Revue rri ired? Yes ❑ No J�"
Brief Description of Proposed Work:_ /��L//cue�� .Z �j q//Z �' � -s-.-
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 Group(s): Proposed Use Group(s): r
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 ap licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3 0 1-4 ❑ 1 M: Mercantile❑ R: Residential R-1❑ 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 ❑ IIIA12� 111E ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
I'rirate❑ or indenlifc Zone: or on site system ❑ required Our trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air.Navigation: NIA I li.tont c ,yinmi��iun Iteir Pr,ro�.•
Not Applicable❑ Is Slructure within airport approach area' Is their review completed?
0 (-nnsant 46,Budd enc6:*ed ❑ Yvs❑ or No❑ Yes Cl No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Gain L'•e GroupW: Tc pe of Construction: Ocaipant Load per Floor'
D,ws the building;cuntainan Sprinkler Scacm?: Special Stipulations:
SECTION9: PROPERTY OWNER AUTHORIZATION
dd� of ro perty-O T . w nC o/
Name(Print) Nu.and Street City/Town Zip
Prop erh Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
Iff y o /�
1licable, the pr( eertwner hercbv authorizes o /
Z 31
J r� t�iO� S�n���
Name Street Addres''s City/Town State Zip
to act on the .ro pert%owner's behalf, in all matters relative to work authorized by this building permit a >plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 350)0 cu.ft.of enclosed s pace and/or not under Construction Control then check here O and,kip Section 111.1)
10.1 Registered Professional Res onsible for Construction Co-n�t-rol
Name(Regisfty�ant n�sNu. a-mail ad'drreess Registration Number
�/ / Te hu
Street Address City/Town State Zip Discipline Expiration Date
-
10.2 G neral Contractor
Companynme: /033,� s/✓
Name of Per su,,,(respunsible fur Construction License No. and Type if Applicable
357� �V% s2c� �oJ�rda eZ O 3/
Street A re City/Town r — Stat Zip
Telephone 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor Q
and Materials) Total Construction Cost(from Item 6)_$ 10-5
�
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal faclw _$
3. Plumbing $ 2 0C2 . - (/, /-\
4. Mechanical (HVAC) $ Note:Minimum fee=$ ntact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:S NATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby, test der the pains and penalties of perjury that all of the information contained in this
application is true aind a orate to th e. of my knowle a and understanding. ���J
vU O/Z /`�f7C/a a ti �tr�/ c�0� — -L!
Please print and i,,•�name Title Tel Vo. Date
;e14
'nIreel Addres, Cite%Town Zip
Municipal Inspector to fill out this section upon application approval:
Name Date