24 WARREN ST - BUILDING INSPECTION F4 !�-j
A x Tile Commonwealth of Massachusetts
� 1
3 Department of Public Safety
Massa'h use(ts Sla to Building Gale I, CAIR)
1uiIdIng Permit Application for any Building other than a One-or 1.1 y Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: . _ Building Official:
SECTION 1:LOCATION('lease indicate Block k and Lot R fur locations for which a street address s not available)
9W IA-
No.mid Street City/Town /ip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
Editiun.ol MA Stale Curie used If New Construction check here❑or check all that apply in [lie two rows below
I nivtiul; Building 5 Repair❑ 1 :\Iteration ❑ I Addition❑ Demolition ❑ (Please fill out and-submit Appendix 1)
Chang'.of Use ❑ Change of Occupancy ❑ Other ❑ Specify: _
Arc building plans and/or nntstnrcliun dw'unuarts being supplied as part of this permit application? Yes ❑ No ❑----
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:.__
-- 1 r IrWl�4 -
SECTION 3:COMPLETE'TEIIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed(See.780 CNIR 1l) ❑
Existing Use Group(s): Proposed Use Gruup(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)h Area Per Floor(sq.ft,)
Toad Arca(sq. ft)and Total Height(ft.)
SECFION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A4❑ A-i❑ 1 B: Business ❑ F.: Educational ❑
1F Facto F-1 ❑ F2❑ I.
fli h Hazed H-1 ❑ H-2❑ H-1 ❑ li-4❑ FI-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-1❑ 14❑ AI: Mercantile❑ it. Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage SI ❑ S-2❑ U: Utility❑ special Use❑and please describe below: -
Special Use
SECTION 6:CONS'TRUCr1ON lYPE(Check as applicable)
lA ❑ 1B ❑ IIA ❑ IIB ❑ IIL\ ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SI'TE W FORMA,rION(refer to-,80 CMR 111.0 for details on each item)
Waler Supply: Pimld Zone Information: Sewage Disposal:
Trench Permit. Debris Realuval: —
Public❑ Check if outside Flood Zone❑ Intlicale uumitipal ❑ A trench will not be Licvnsvd IlisI'osal Sit'.❑
I'm ate❑ or indvntifs /one --.-_-- or on Site Sislem ❑ required ❑or trench or specify:-_..-_
permit is enclosed❑Railroad right-of-way: Hazards to Air Navigation: N1 I;,,k . ,Wi.. 1,
.Not A11111 cabl'.❑ Is Slructurr within airport approach area? Is Ihvir rev ivw c,oll+It.w:1
nr C nll Sent to Budd vnclu1xrl ❑ 1 es❑ or.No❑ ' Yes❑ No 0
SFC 1 ION H:CON FENT OF CFRTIIICATF OI'OCCUPANCY
FJilinn od Code: �.. L so Croup(,) _ fti,v of Conbinitlioll llCcu pout I�,,pl per I'Inor.
I)oe, die build oil; strain an Simn kIcr Sy stem.': _ Spn 1,11 Slipulatiens: _ - - -
SEC'1'I0N4: PROPFR IY OWN FRAUTI IORIZA"IION
Nome and Addy-ss of Prpperly Owner —
L1 - IQ -- - - - ---------- --�-tea
N,une(Prim No.and Street City/Town Zip
Properiv Owner Contact Information:
I'tlle relephone No.(business) Telephone No. (cell) c-mail address
If applicable, the property owner hcrebv authorizes
-__- Name -- Street Address City/Town State Zip
w act on the property owner's behalf, in all matters relative to work authorized by this buildniF permit a ,plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is ICS9 than 35,0Q)cu.ft.of enclosed s pace and or not under Cunstruction Control then check here O and skip Section 10.1
I0.1 Registered Professional Responsible for Construction Control
11
c-m Nantc(Rcgistra tp) Tticpuonsu. ailaddress�� Registration Numbe
13 1 47LN�11f•�1 1 n„ r�4 n►9
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Qer,-Y fi1�
Company Name t� �
L-? t- I-=ey ty �aa t(Qy44�
Nance of Person Responsible for Construction License No. and Type if Applicable
,Street Addressss�'�Q City/Town State Zip
Tole phone No. business Telephone No. cell e-mail address .
SECTION 11:tea v<f.l,r. t t AlllV,a rla IN I.Nt•Int\.`c'I AI 111 11 M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
subntitled with this application. Failure to provide this affidavit will result in the denial of thy�Seance of the building permit.
Is a signed Affidavit submitted with this a lic atiun? YestEl No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost((ram Item 6)=S_
I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Elcclrical 5 appropriate municipal factor)=5
3 Plumbing S
a. \Iechanical (HVAC) 5 Note: \lininnun fee=S _(Contact municipality)
3. Mechollical Other S 00 Enclose ihtx'k payable h,
I,.Total Cast $ (contact municipality)and tarite check number here _----
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
13v entering my name below, I hereby altest under the pains and penalties of perjury that all of the in formal it'll contained in this
application is true and ociuratc h,the best of my knowledge and understanding.
Please print and sign name Title Ivlcplook.No. Dale
titrccl .\Jdr•ss City/Pawn Stale /ip
Municipal lnspectur to fill out this section upon application approval: --_. _.-------------_--- _---
m'
lilt
9��lMINB Wit .
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
Reconstruction g Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District:_ McIntire
Address of Property' 24 Warren Street
Name of Record Owner: Richard Jacolta
Description of Work Proposed:
RerooJ carriage house with GAF Timberline black architectural shingle.
Dated: April 9, 2012 SALEM [ STORICALLCCOO/oNI�MISSION
By:
The homeowner has the option not to commence the work (Unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
H [IS IS NOT A BUILDING PERNII'f. Please be sure to obtain the appropriate permits from the Inspector of
13Uildings (or any other necessary permits or approvals) prior to commencing work.