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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only) -
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Washington Square Salem, MA 01970 Washington Arch
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of MA State Code used 8th If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair® I Alteration ❑ 1 Addition❑ 1 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 ❑ No C1
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
Remove existing ornamental carvings_
.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):
't.' 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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Fad F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use M and please describe belowm
Special Use: Ornamental site features, not a building
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ IV ❑ 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:
Public❑ NIA Check if outside Flood Zone CK Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site sys 4m❑ required M or trench or specify:
permit is enclosed❑ N/A
Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process:
Not Applicable® Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed❑ Yes❑ or No M Yes❑ No N
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
City of Salem 93 Washington Street Salem 01970
Name(Print) No.and Street City/�TO�'/ry Zip
. _ r_.._ _ lion:
Property wnerContactlyd'orma 978 745 9595 � -- - -
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ,,.
If building is less than 35,000".ft.of enclosed s p ace and/or not under Construction Control then check here M and stop Section 101
10.1 Registered Professional Responsible for Construction Control . `
Mark Meche 978.744-7379 mmeche@wsarchitects.com 7083
Name(Registrant) Telephone No. e-mail address Registration Number
209 Essex Street Salem MA 01970 Architect 8/31/2014
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
No GC this stage
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 $ 0 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ ) (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By 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.
Mark Meche Architect 978-744 7379 1 1/1 4/201 3
Please print and sign name Title Telephone No. Date
209 Essex Street Salem MA 01970
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval•
Name Date
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Salem Historical Commission
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance,
application is hereby made for issuance of a Certificate of Non-Applicability as described below for:
CI New Construction ❑ Moving M Reconstruction ❑ Alteration
Demolition ❑ Painting ❑ Sign K Other
District: ❑Derby Street ❑Lafayette Street 0Mcintire ❑Washington Square
Address of Property: Washington Square
Name of Record Owner(s): City of Salem
Owner Mailing Address: 120 Washington Street, Salem, MA
Description of Work Proposed:
Initial stage is to remove and stabilize the carving on the 1976 Washington Arch.
See attached for additional detail.
photosjApplications must include • conditions,
Winter Street Architects, Inc. for '
Name of Applicant:Salem Common Neighborhood Assoc. ❑Owner ❑Contractor ❑Tenant NOther- consultant
,Tel. #: 978.744.7379 E-mail Address: mmeche@wsarchitects.com
Certificate will he mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name Ann Sousa, SCNA,
Mailing address: Po sox 8608 City: Salem State:MA Lip: 01970
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Salem Historical Commission
120 NdASHiNGTON STREF_T, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Constriction ❑ Moving
O Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑x Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch_ 40C) and the Salem Historic:
Districts Ordinance.
District: Washington Square
Address of Property: Washington 4nuareSalem Common
Name of Record Owner- C, Ly of Salem___
Description of Work Proposed:
Tcwporary removal and protection of the McIntire Arch.carvings. The carvings will be restored, repaired, and
reinstalled as part of the McIntire Arch preservation project scheduled for Spring 2019.
Non-applicability dr.ne to 14107-k being in-kind repair and temporary removal.
Dated: November 7, 2013 SALEM HISTORICAL COMMISSION
By:
The homeowner has the option hot 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.
i
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.