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5 CEDAR AVENUE - BLDG JACKET®� 5 Cedar Ave. G APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT IMPORTANT — Applicant to complete all items in sections: 1, 11, 111, IV, and IX. O —/� ZONING I• AT (LOCATION) �+=" \� !f DISTRICT LOCATION (R0.) (STREET) OF BETWEEN AND BUILDING (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT BLOCK SIZE II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D 1 z A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m rn 1 ❑ New building Residential Nonresidential 2 ❑ Addition(If residential, enter number 12 One family 18 ❑ Amusement, recreationol of new housing units added, if any, in Part D, 13) 13 ❑ Two or more family — Enter 19 ❑ Church, other religious number of units— — — — i 3 � on See 2 above) 14 ❑ Transient hotel, motel, ❑ Repair, paireplacement 20 Industrial 4 RRa 21 or dormitory — Enter num be> Parking garage 5 ❑ Wrecking (If multifamily residential, of units ------- — y 22 ❑ Service station, repair garage enter number of units in building in 15 ❑ Garage 23 ❑ Hospital, institutional Part D, 13) 6 ❑ Moving (relocation) 16 ❑ Carport 24❑ Office, bank, professional 17 ❑ Other — Specify 25❑ Public utility 7 [:] Foundation only 26 ❑ School, library, other educational B. OWNERSHIP 27 ❑ Stores, mercantile 8 ❑ Private (individual, corporation, 28 ❑ Tanks, towers nonprofit institution, etc.) 29 ❑ Other — Specify — 9 ❑ Public (Federal, State, or local government) C. COST (Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food processing plant, mac.tine shop, laundry building at hospital, elementary 10. Cost of improvement,,,,,•••••,,,••, school, secondary school, college, parochial school, parking garage for, department store, rental office building, office building at industrial plant. To be installed but not included If use of existing building is being changed, enter proposed use. in the above cost a. Electrical....................... b. Plumbing ....................... c. Heating, air conditioning......... d. Other (elevator, etc.)............. 11. TOTAL COST OF IMPROVEMENT s O III. SELECTED CHARACTERISTICS OF B ILDING — For new buildings and additions, complete Parts E — L; for wrecking, complete only Part J, for all others skip to IV. E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS s 30� asonry (wall bearing) 40 � 48. Number of tories..............' ublic or private company 31 Wood frame 41 ❑ Private (septic tank, etc.) 49. Total square feet of floor area, all floors, based on exterior 32 ❑ Structural steel dimensions ..................... 33 ❑ Reinforced concrete H. TYPE OF WATER SUPPLY 34 ❑ Other — Specify. 42 ❑ Public or private company 50. Total land area, sq. ft. ........... 43 ❑ Private (well, cistern) K. NUMBER OF OFF-STREET PARKING SPACES F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL 51. Enclosed ....................... 35 ❑ Gas Will there be central air 52. Outdoors........................ 36 5;a'6iI conditioning? L. RESIDENTIAL BUILDINGS ONLY 37 ❑ Electricity 44❑ Yes 45 ❑ No 53. Number of bedrooms.............. 38 ❑ Coal 39 ❑ Other — Specify. Will there be on elevator? 54. Number of Full.......... 46 ❑ Yes 47 ❑ No bathrooms Partial........ NOTES and Data — (For department use) �- e2, e i e 1 C, L"L S IV. IDENTIFICATION — To be completed by all applicants Name Mailing address — Number, street, city, and State ZIP code Tel. No. 1. Owner or �" 0. 7 � Lessee V eir Forb W f� cie:, C �• Q License No. Contractor j 3. Sal l Architect or Engineer I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction. Signa tur op cant Address Application date 10�z�6—�Y ci DO NOT WRITE BELOW THIS LINE V. PLAN REVIEW RECORD — For office use Plans Review Required Check Plan Review Date PlansB Date Plans B Notes Fee Started y Approved y BUILDING $ PLUMBING $ MECHANICAL $ ELECTRICAL $ OTHER $ VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS Permit or Approval Check Date Obta ned Number By Permit or Approval Check 0 Date ned Number By BOILER PLUMBING CURB OR SIDEWALK CUT ROOFING ELEVATOR SEWER ELECTRICAL SIGN OR BILLBOARD FURNACE STREET GRADES GRADING USE OF PUBLIC AREAS OIL BURNER WRECKING OTHER OTHER VII. VALIDATION Building - FOR DEPARTMENT USE ONLY Permit number Building Use Group Permit issued 19 Building Fire Grading Permit Fee $ :�Z r U Live Loading Certificate of Occupancy $ Occapancy Load Approved by Drain Tile $ Plan Review Fee $ TIT r VIII. ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES IX. SITE OR PLOT PLAN — For Applicant Use . F» µ .F+ r�7 x...,+t.- ryiv�-, i,—.t—... + +•+�,—r- —7}.. --i—r {. r ,. +-4' "1`$r"T «...r+.si. +-+'_''r.,.. -4;� 4 -fr +- r j J .{ [9rj-tj ST -+ C _ ,+•'_ f JJ+ tjt «Y—r ` +-.- 2i3.'-.!Y1- j + } s j_71=— :,7 r , a z N 1z, i r - Fi T �$ 4 + r }. + ^ v:--t+ • ' ^t. .eYYr. rt ,L .. ..i ,+4++x+4 r2 'Et ,+ { i, ri T i 7 + % 7 -^s. ....{ + 5 . . .. .a,i 4}{.;�:alt BCCA FIRM APEBP — 669 C1969 FL11...n I.YG OFFICIA.l t COP' AOM11115Ti:AiOPO INTE9tATIONAL. IN4: � v COMMONWEALTH OF MASSACHUSETTS cc JEFAR:MENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET _gimes. �anoper. BOSTON, MASSACHUSETTS 02111 WORKERS' COMPENSATION INSURANCE AFFIDAVIT �L I 1 0 r ©G� !hcenseeipermincel with a principal place of business/residence at: j Yaj l/ 2 rC 44G` (.,) `' (City/Stare/Zip) do hereby certify, under the pains and penalties of perjury, that: ] I am an employer providing the following workers' compensation coverage for my employees working on this iob. insurance Company Policy Number j 1 am a sole proprietor and have no one working for me. ] I am a sole proprietor, general contmaor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: Name of Contractor insurance Company/Policy Number vame of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number [ I am a homeowner performing all the work myself. *NOTE: Please be aware that while homeowners who employ persons to do maintenance.construction or repair work on a dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto arc not generally considered to be employers under the Workers' Compensation Aa(GL C. 152,sea. 1(5)), application by a homeowner for a license or permit may evidence the legal sums of an employer under the Workers' Compensation Act. understand that a coov of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage +enfication and that fatiure to secure coveraze as reouired under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to 51500.00 andlor imprisonment of up to one year and civii penal ues in the form of a Stop Work Order and a ..ne of 5100.00 a day against me. Sicned this day of 19 ' icenseeiPermiaet: Licensor/Permiaor CITY-O-F SALE PUBLIC PROPERTY DEPARTMENT KIMNFRI-EY DRISCOLL .MAYOR 120 WASHINGCON S�MEEr♦SAIFM,MASSACHLSEM 01970 TEL-978-745-9595 • FAx:978-740-98" APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: Property is located in a; Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.4 Owner of Land Name: Address: 5 a—.- S oQa�vLrk7 4 0 / Y76 Telephone: 97--7 ¢V_ Ypcf 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: What is the current use of the Building? Material of Building? If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architects Name Address and Phone j Mechanics Name Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of Pr je $ " Permit Fee Calculation Permit Fee $ b Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date o d N O a+ V a F' l C7 > CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIAOSELLbY Uel50DLL 120 WAyaN=W SrmEr#SA EK lsEm 01970 NAYW Ma-•973-74i9593*FAX:97b740-98d6 Construcdon Debris Disposal Affidavit (required for all demolition and renovation work) in accordame with the sixth edition of the Stan Building Code,780 CMR section 111.5 Debris,and the Provisions of MGL c 40, Building Pen�nit M iss issued with the condition that the debris resulting froth in a properly licensed waste disposal facility as defined by MGL c this work shall be disposed of 1 11,S 150A. The debris will be transported by: WM , "To4 NJ -c0?+� (name of a) The debris will be disposed of in : y�f S C mR-T , W (name of facility) S W rrtPsc /7 kc(— _ (address of facduy) sigeatum of pemur applicant dW meri,�7.Wc i CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIMBERI.EY DRISCOLL MAYOR 120 WASHINGTON STREET• SAIFM,MASSACHUSETTS 01970 TEL*978-745-9595 • FAX:978-740-9846 HOMEOWNER LICENSE EXEMPTION Please Print Date 9- / Z— e) 6 Job Location i C 6'4#,< 11 v Z Home Owner Address S Am E Home Owner Telephone 9 7 F—7 g V 4 7 V S Present Mailing Address SAME The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who,does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING INSPECTOR See other side for state code I Homeowner's Exemption The Code states that: "Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section(Section 109.1 —Licensing of Construction Supervisors);provided that a Homeowner engages a person(s) for hire to do such work, and the Homeowner shall act as Supervisor." Many Homeowners who use this exemption are unaware that they are assuming the responsibilities of a Supervisor(see Appendix Q,Rules and Regulations for Licensing of Construction Supervisors, Section 2.15). This lack of awareness often results in serious problems, particularly when the Homeowner hires unlicensed persons. In this case your Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The Homeowner acting as Supervisor is ultimately responsible. To ensure that the Homeowner is fully aware of his/her responsibilities, many communities require, as part of the Permit Application, that the Homeowner certify that he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. I�