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46 MARLBOROUGH RD - BUILDING INSPECTION The Commonwealth of Massachusetts W Department of Public Safety Massachusetts State Building Code(730 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling t' (This Section For Official Use Only) IAn n Building Permit Number: Date Applied: Building Official: t SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) LO bo. No.and Street City/Town Zip Code Name of Building(if applicable) 1 SECTION 2 PROPOSED WORK FEdition of NIA State Code used If New Construction check hereor check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix l) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? YcsX No Cl Is an Independent Structural Engineering Peer Review requirckl?� /`' q ( a O t Yes ❑ Noli Brief Description of Proposed Work: 57f /4GT r,L yx 7 u9nle55, A^ 64-c. 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 a N bie) A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 ClA-5❑ B: Business ❑ 1 E: Educational ❑ F: Facto F-I❑ F2❑ IL• High H"ard H-1 ❑, H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility 6z 1 Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ HA ❑ IIB ❑ IIIA Cl Hill Cl IV O 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: A trench will not be Licensed Disposal Site l� Public 0 Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: in.l I� 1 ��_�'...p..�k'i n I ,.w, Ira: c Not Applicable Is Structure within airport approach area? Is theii review completed? or Consent to Build enclosed❑ S , Yes❑ or No Yes❑ No ITC SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Cgde: Use Grou p(s):_' ' . Type of Construction: Occupant Load per Floor: Does the building cmlain an Sprinkler System?: Special Stipulations: __ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Gay d iF 53 W4,,,54- 5hieef ©/5>o Name(Print) No,and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. 4 SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,600 cu.ft.of enclosed space anJ or not under Construction Control thencheck here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Tele o. a-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - - Company Name CS ©q s ? 3 `-1 Name of Person Responsible for Construction License No. and Type if Applicable �— Street Address City/Town State Zip �Lfi S G YU �i71T- 375- 6o�SL T 5'7'-X-Iel e !� Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKWS'COMPENSAPON INSURANCE AFFIUAVI'l M.G.L.c.152.9 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 a lication? Yes 0 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)=S 3. Plumbing $ d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 1050Q (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my t me below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is t to and accurate) th•be f my knowledge and understanding. / L(24,„ re-,-g .o� W 6/9- 5lo Y D Please prime sign name Title Telephone No. Date 1 hO.Ka5 J� e L _ _ Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: 08 " - Name Date rj aCITY OF SALEK MASSAaivam BuiwiNG DEPARTAamr 120 WAsmNGwNS7REET,3'DFWoR 7kL(978)745-9595. FAX(978)740-9846 KIIv16ERL.EYDRiSO�LL MAYOR 7 1 r STYIERRE DIRECTOR OF PUBucPROPERTY/BumDm ooiaassiom Construction Debris Disposal Affidavit (required for all demolition and,renovation workf In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit#1 is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: vp (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of app 'cant e ;�452 /'! 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RPe�I�Er1.,SmI Ia6 __-_ ' --_-_-_- -_-_-_--_- _- _____ Tt�w $Purls r -� Al LeFf Elevefsrn Rer Elevaflan wa v.-re 1 \ �f \ \ WOW P33753 P33754 40, gV 0 J / Patl W7 4 m / P33752 �e `\ P337S1 a lJ P3375 P3375-e4 / 32 / Exhibit A-Not to Scale The exact location of said Facilities t be Established by and upon the installation and Erection of the m Existing J/0 Pole ® Proposed 1PH Facilities thereof. Primary Riser r1$ Proposed S/OPole Proposed OH Primary f�Y ational ri d Proposed S/0 Anchor ————— Proposed UG Primary EASEMENT SKETCH 46 MARLBOROUGH ROAD CEProposed 25KVA Proposed OH Secondary SALEM,MASS PadmountedXfmr ITT.—E 1210049