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15-17 LEAVITT ST - BUILDING INSPECTION ill4i The CommonwealthofMassachusetts Department of Public Safety Vr_,,,•i' .\IaSSarhusc•ttS State Building Code(780 CMR)Seventh Edition City of Salem _ Building Permit Application for any Building other than a 1- or 2-Family Dwelling (This Section For Official Use Onlv) Building Permit Number: Date Applied: 6 Building Inspector: SECTION 1: LOCATION (Please indicate Block B and Lot M for to ations 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 all 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 ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes )4 No ❑ Is an Independent Structural Engineering Peer Review required? p 2 Yes ❑ No ❑ Brie fj Description of Proposed Work: T»-31`4df df 1 e-Ae-Ira. / ri%k "I •halt y � s� d di«�1Ms �l'r HlFift 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): t• 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ 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 ❑ IIIA ❑ IIIB Cl 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: PoHIC❑ Check if outside Pl ood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑ required ❑sir trench or Spcafv: I'rivale❑ or indenli(y Zone: or on site svaem ❑ permit is enclosed ❑ Railroad right-of-way:' Hazards to Air Navigation: \I.\ I flMnrlCc nnnis�im Kr.ion+ Pm;r..; \nt Applicable ❑ I.tilnii W ee�cuhin airport approach area' IS their re,iew completed.' a l m�cnt W ISuild enclosed ❑ YeS❑ or.No❑ Ye Cl \o O SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition nl C ode: l.e C�roupt J: ivpe of Construction:. Ocnipant Load per Iloo r: D,w,the building conta nan Sprinkler'%% tem': Special Stipulations: /l Ic. 7-d : 5grtc 11�2+uCEEtriJ r SECTION 9: PROPERTY OWNER AUTHORIZATION r Name and Address of Property Owner very► 01 T Rer trr J-e . 38G1 ¢r,P•t ie.va/ 7st oi9 P Name(Print) No and.treet City/Town Zip Property lhvner Contact Information: oewjr.*- ep - - y^s sQi eP7b'_ yl5- /5 3P Title Telephone No. (business) Telephone No. (cell) a-mail address If applicable, the property owner hereby authorizes Name Street Address Citv/Town Stale Zip to act on the pro perh owner's behalf, mail matters relative to work authorized by this buildin • permit application. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) . I - : I I . I• , (If buildin•is less than 35,000 cu. ft.of enclosed s pace and/or not under Construction Control then check here❑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 0 el,441'Y 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: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 mum pal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ .4-6 (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT Bv entering my name below, I-hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Please print and aign mime Title A•Icph No. )ate }treet Address City/Town State Zip r Municipal Inspector to fill out this section upon application approval: !� Na rdV Date CITY OF SALEM PUBLIC PROPRERTY a / DEPARTMENT M W.,;1 i1.\c;uN 5 rH u r • S.t i r M. Trt:978-'43-9395 •F.tx:978-74S/846 Construction Debris Disposal Affidavit (required I'ur all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tr.- - _ is issued with the condition that the debris resulting front this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 1 11. S 150A. The debris will be transported by: ptame uh haulzr) fhz debris will be disposed of in 1 (nameut aciiry) (address Ile raC1111Y1 signatureAe-o tx nlcant q/ .,late • FROM 883A1 (TUE)MAY 29 2007 9414T. 9:40/NO. 6318800274 P i SURVEY SKETCH 16-17 LEAVITT STREET SALEM, MA., DATE: 91-28-06 SCALE: 1" = 20' - 1 HEREBY CERTIFY THAT WE HAVE MONUMENTED THE LOT AS SHOWN BY AN INSTRUMENT SURVEY_ BAY STATE SURVEYING ASSOCIATES INC., 900 CUMMINGS CENTER, SUITE 316J BEVERRLY. NW. 01915 O ��gg s-r v, P /r GG E�16t�" NAfI— Sr--r 38,s' fj 0 � '� srtKE �rnGc � s�T tiC i HARDY *jf of cCAvrrr s' for 4.9AVarr 5T. Woburn: (781)933-9363 Salesman PRE-SALE INFORMATION . Peabody: (978)636.3635 �( Type of Fence Waltham: (781)990-6105 Appt.Date _ FENCE C Oa Braintree: (781)3SO4800 !0 Merrimac: (978)346-0007 APPt.Time Footage/Gates of the NORTH SHORE,INC. Plaistow: (603)3824004 293 Salem St.,Woburn,MA 01901 Toll Free: (800)321.9363 Source of Lead Budget Quote WWW4RELIABLEFENCEBOSTON.COM Fax: (701)933-9304 tal Submi d t Job Location: - 15-17 a-tity streer 5 R_8 Directions: ,� o City,State,Zip I Comments fault; . 0 4 aas Phone cell Fax E-mail Work 9 - � TERMS & CONDITIONS SCOPE OF WORK Fumish & Install PLEASE READ CAREFULLY Footage Heilght Style otage Hei t Style 1.ALL ORDERS ARE CUSTOM MADE sent are limited to the 6D Qt 1 B rs scope of work as audined.Any additional work will be billed at $g5,00 par hour including travel time plan necwary materials. V1,041C 1 SQgCtAl Quote is based an condition at date of proposal.Customer is responsible to notify RFC of any changes. !SuC L Crrstemw is to char proposed fence lies prior In installation I' u of as obstrueaom A clear area 18"from the center line of Posts 'L6 f�� " Posts fence on each side is required for proper Installation NOTE:Reliable Feoa cannot be responsible for shrubs or Dowers within 36"of proposed fence lines.Customer should tie back or remove an planting they wish to protect. Rails 31C " R,J,( OK Rails 3 ,f, rvs+—" 3. Cmbmer is resporndble fo comet DigSafe sf 868:7de-7233. (RFC ID a 16551n, 4. Customer to elearhy,mark an underground utilities.Reliable is not responsible for any damage to any underground utilities Trim 'fries (sprinklers,gas lines,electric,etc,)that are no elearty marked. •5. Every city and town has differing regulations and restrictions Gates AjOAX_ Gates regarding fencing.The customer is responsible for conforming I. , tal ordinances&OBTAINING PERMITS IF REQUIRED. Misc. disc- 0 it 0� A-iJ 4 ��_'Iperty customer is responsible for establishing and marking all lines and providing survey marking,if necessary. © ❑All gates With steel welded no sag frame ❑ Other 7. Customer to provide an active water source and live Q All wood materials natural/no stain electrical power outlet a RFC cemat remote excess sed and rocks from property. Q Take down and removal of existing: Ancillary asphalt work responsibility of owners. INSTALLATTON CHECK LIST: . ® Price does rant Include disposal of cement bases-Add$30.per base for disposal. Clearing LAYOUT: F Indicates Facing of Fence Tree/Shrubs Obstructions Pins Access Ledge/Blasted Rock a - Misc. Equipment t Cmce to Follow Grade ❑Fence to Step to Grade it fC I . . The slope of your Property will dictate how much spas will be under fence. SPECIAL/OPTIONS e 37'ok 4 'vII back oyt�l ch S�S � - 'T'me Svcs l asO- All 1OLLS -\,Ato c&cte\?-. Additional site Check Required THANK YOU FOR CONSIDERING RELI.A LE FENCE ❑ This project is priced on a"fin in"basis and We Propose hereby to furnish materials T probably will be done without notice.If you and installation in accordance with the $ X P T75 —require a scheduled date,add s l90 to quote. above specifications fo um of: C ck 700' PAYMENT OPTIONS: ❑ Cash/Check-50o/a Deposit with Balance COD BY: _ Date ❑ MastercardNisa- IOOa/o.Advancl;Aevment This Proposal may be withd by RFC if not accepted within 10 days. Speei'1QTs tJad�tp� Acceptance of Proposal The above prices,specifications and conditions are satisfactory �tn00- and hereby accepted.You are authorized to do the work as specified.Payment will be made ,L""" a iJQgtA„ �hct offer• as indicated. All materials remain the property of R.F.C.until final payment is received. f<8t try 1 understand th cel ay,be subject to a service charge. A sery n per month(18%annual) wit ed on all Past Due Balances. X Date //