1000 LORING AVE - BPA 10-868 MODS. WIRELESS ., The Commonwealth of Massachusetts
1, Department of Public Safety
�(. 'i• \1a.achuxtls`mate Building Cade(780 C\IR)`:venth Edition
v u
City of Salem
Building Permit A lication for any Buildinn other than a 1-or 2-Family Dwelling
(This Section For Official Use OnIV)
Building Permit Number: Date Applied: Building Inspector:
SECTION is LOCATION (P)ease indicate Block 0 and Lot 0 for locations for which a street address is not available)
woo LoVLh(A QaUhr C010 l nrjn/TTmuPr�
No.am{Street Cin' /Town Lip Cawfe Name of Building(if applicable)
SECTtObFrPROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration id Addition❑ Demolition O (Please fill out and submit Appendix 1)
Cha nge of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plan,and/or construction documents being supplied as pan of this permit application? Yes No O
❑
Is an Indrpendmt Structural Engineering Peer Review required.
Yes No
Brief Description of Proposed Work: T(OVt 111 l
sECT10N 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING AENOVATYON,ADDI770N,OR
N P CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O r
Existing Use Group(s): Proposed Use Gmup(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
sECI'iON 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flexirs/Stories(include basement levels)&Area Per Floor(sq.h.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION k USE GROUP(Check as applicable)
A: Assembly A-1 O A-2r O A-2nc❑ A-3 O A4❑ A-5❑ 1 6: Business ❑ E: Educational ❑
it
F: Facto F-1 ❑ F2❑ 1 H: nigh Hazard H-1❑ H-2 O H-3 O H4 O H-5❑
t: Institutional 1-1 ❑ I-2❑ 1-3❑ I-1❑ 1 M: Mercantile❑ Ri Residential R-10 R-2❑ R-3❑ R-f❑
s: Storage S-1 ❑ 5-2 O U: Utility❑ Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as Applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIAO 11180 IV TVA VB ❑
SECTION 7:SITE INFORMATION(refer to 760 CMR I11.0 for details on each item)
- Trench Permit:Nw A Debris Removal: (�
Water S ply: Flood Zone Information: / Sewage Dispos : ,\trench.vdl net
la/ Licen,ed Di.p,is.d Site
Pubhc❑ check it unlade Fbnnl Luna•P] Indicate momcipal❑ requira❑or trench ur.pecifv:
Private❑ .mnJentifc Zone:_ ur un ate wtem ❑ permit i,endri.rd❑ _
Hazards to Air Navigation: �L\ I ha.•n. O ...............I(.• .. V1,•.r•
j Railroad right-of-aw�/av: g ��
\ul . pplii.ddctl .1.�ou<turc to nhm.urpnrt.if�•n�.tch.trr.t' LIhrir.e ivtvr...nplovd,
r l �n•rnt to Rudd end.�.rd❑ + j\eI❑ �r X..f� )v,❑ \.. ❑
SECV : 'OM1TENT OF CERTIFICA fE OF OCCUPANCY
TIO. 8 C
I:.ionm.d l'�ale _..__ Lvl:nm .m.uucuun. Occupant l...id per liner
Ih tl b li C It t 14pnnkler Special Supulatwn.
SECTION 9:
�� {{ � n � l �'•� PROPERTY OWNER AUTHORIZATION
Nameandlddress,il Pnwrrty Owner
Imm (hVE S 1S �� D nOMd 2eO
Nnd r Cih/Town
Lit'
\amr(PnnU N�
Proprrtvt)wner Contact Information: 3 7
Title IV WY. Telephone Na-(business) Telephon/e�No. (cell)� p A�t�a-mad address
IIh`O I�.I�r.S a properly owner hTtbV'authut I�CiA 3fy t%�� 1717�1 J`�— U��
/( Name 1� Street Address City/T,,wn state Zip
io act on the pro perm owner's behalf, to all matters relative to murk authorized by this buddin• permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If FuilJin•is kss than 35,000 cis.n.of cnckpvd space and/or not under f.pnstruction Contmi then check here D and skip Sectiun 10.11
10.1 Registered Professional Responsible for Construction Control
a.rr C4,e, Am qo1 -�M mere.- ' 122!902 nef 4032
Name� ((Registrant) Telrph�ne No e-mail address Registration Number
�I a;ALJ241tYfLI 1 6_ cf 1>roV1(�Pfrp� _ � MV1I
Street Addrm) City/Town state Zip Discipline Expimt can Date
10.2 General Contractor
(Jar�el�cLs4�¢m�f `Pf�o,,,. � aaP On� OrC
Co Nam : r-41) CS LI'2AO -
Name t Person Res msibl fur unstrudiun tense No. and Type if p licable
-,iz. try Mor(�lehvar�
S�t�r�t Address City/Town State ZiP
�571 0.. �'�b —— 1��stur /P VlP D�.d�cam m M
Telephone No.(business) Telephone No.(cell - e-mail address
btLTl lON ii:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M_G_L.e.152.§2SC(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 a lication7 Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item tEst�imated :(Labor ,1tnals) Total Construction Cost(from Item 6)=EAg)1. Building Building Permit Fee=Total Construction Cast x_(Insert here2.Electrical appropriate municipal factor)3.Plumbing 4.Mechanical (HVAC) Note:Minimum fee=S (contact municipality)
5.Mechanical (Other) Enck a check payable to
6.Total Cost (contact munici lit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bc entering my name below. I hereby attest under the pains and penalties of perjury that all of the information contained in this
Application is tme.md accurate to the best of my knowledge and understanding.
GIn V�tan t�tlyflvryarl P��raates Net Cilb-FA(P 4�s4
1' per pant.cod,ign name ritlr relephone\u. Date
p VUP S+fi P.� f Ica k O I
1
tit re'l C it.%;Topc'n State Zip
%lumcipal Inspector to fill out this section upon application approval: �+- r
\ame I la te__�