2 & 5 WATERS ST - BUILDING INSPECTION City of Salem Ward
. ,
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete allitems in sections:4 11, tit, IV,and LK.
�l
1. AT fLOCAT10N1 C / y J7"ECr ZONING
LOCATION /1N40.1 �/ ( � S
TRICT
LUL /
OF BETWEEN A5t7 (� AND gcfij/
BUILDING CRosssmEETI ICRosssman
LOT
SUBDMSION LOT_BLOCK SIZE
11. TYPE AND COST OF BUILDING-All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOUTION"USE MOST RECENT USE
t ❑ New budding Reside tell Ndreeatleraw j
2 ❑ Addition rn residential,end num&era new 12 IXI one hmiy is Q Amueemea.n tl
housing units added.d any.inpan D.131 I'-'� is Q Cmick other relgnus
13 ❑ Two or more family.Enter number 20 ❑ IrlatbiY
3 ❑ Aoerstcn ISM 2 aboeel of units--
4 ❑ Repast replacerner l 14 ❑ Tranwn hoes.maul or dormilory- 21 ❑ Perei g garage
Enwmrmbwof unit 22 ❑ $eA"0°mum 1epw Below -
5 ❑ Wreaking In muAefamiy resider"ode Mentor 23 ❑ fepepaaL nelnlgrtl
of units in&wiling in Pan D. 13) 15 Q Garage 24 ❑ Qlfibe,bank paeseorW
6 ❑ Mourn(rewa4en) 1s Q Carport 25 ❑ Pulse:utity
7 FGundatwonN 26 ❑ Sclroo,MNM alw aduea&aW
n ❑ tied•spear � �UPL�
27 ❑ States.mercamit,
8. WNERSNIP 41^1 1 TS Z IJN/TJ) 2e ❑ Tarae,opwam
B Private luvdividWL Corporation.rlonprofd � peury
ion.etc) 29 ❑ Onw•S
/y /�"!•L�
9 ❑ Pudic IFedew.Slate,or Ions goverment U7+(D/tlr7 O R/,
C.COST (Omd Centel Naresrtlsmel-Describe In dams proposed use at buildings,e.g.food prooeYerg pan
rzv140 }7 mvf MAMM erica,laundry bidding at hospmL ebMw war Sr1wd.SewndarY tam.College.
10. costal dnprovemeM .—071i L4 t Q O0 otrlel aeo aolrbol.paring garage for de=brMR Stan.rents GII=buedM ono Duelling
at awun&el o t d use a eaetmg bw"m berg chmMK enter Prcaceed all,
To be nettled but not Mk~
in se Move cost L A Q� 1;7 ✓1 5 044
a Electrim--- '
b. Plul ON
Neelag,w ooMia&Ming.
d. oow lelevaw.ter) .--.
/1. TOTAL COST OF IMPROVEMENT
IIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-I"demolition,
complete only Parts J&Mall others skip to IV
E PRINCIPAL TYPE OF FRAME F. PRNCFAL TYPE OF HEATH FUEL G. TYPE OF SEWAGE DISPOSAL I. TYPE OF MECNAN AL
30 ❑ MWM(vine I M g) I .35�Wall 40�PrElc or Prlvete pompeMy Will awe be beret w
..32 ❑ S1ructuesleel 37 ❑ Elsoidly _01.❑ PdWelsep&c'e,nK ec.l .?7tfMe 45 Q No
33 ❑ Raedoreed port rqa, 38 Q Coal K TYPE OF WATER SUPPLY WYI Care by an eWAW
34 ❑ Oyw-Spray 39 ❑ Oaer•Specdr 42�ubdc or Praise,collide" 46 ❑ Y" 47,&No
43 0 Private hued.cleterMt
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48 Nulnoef or 510ne5 ...__..........
.__................................._.
ae. Teat actuate ten of floc,area Has Approval from Histoncal Commission been received
aow& s
a:: a5...an a,�
a..m .. y�.. 3 3(ea� for any structure over fifty(50)years? Yes_ No_50 Total una Ma.W.ff.......�pl,2 . q r,p.(y.-- Z l (.33 Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES / Pest Controll:
51 --
�� HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
sz. ouaoors...._..._.__..-_.._.._.._'--'----_....— Yes No
L 5ESIDENTUL BUaDINGS ONLY Water:
53. FJ,doxo � /O Elet:tric:
Gas: .
Full— 2 .Sewer:
-50. Numon of '
oadaop,e DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
? ---- l BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No-X (if yes,please enclose documentation from H'rsL Colin.)
Conservation Area? Yes_ NoZ- (If yes,please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes , No_
Is property located in the S.R.A. district? Yes_ No_
Comply with Zoning? YesZ_ No_ (if no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No_ (If yes,submit documentationfd no,submit Board of Appeal decision)
If new construction, has the proper Routing Slip been enclosed? Yes_ No_
Is Architectural Access Board approval required? Yes_ No--Y (If yes,submit documentation)
Massachusetts State Contractor License# C S 0 8 S Salem License#
Home Improvement Contractor# 3 Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
)� If an extension is necessary,please submit
CONSTRUCTION IS TO BE COMPLETED BY: 3 C, in writing to the Inspector of Buildings.
V. IDENTIFICATION - To be completed by all applicants
Nana Mghn addea•Nuf er.srfaet CO,ono Oft LP coda Tel No
NORTFF tzI /trTt- e7t.A4L S'>" p/ � 7
Owner or
Leam QU et41WtWr u 1 .4 7K 3 0+3
2. i/.tc. l 9 9 .
oo&J2 01 6 wm 06`fbs
3. Of-7
AnIaW o,
pLc/1fi2� 0�3
I hereby certify that the pro work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his atahonzed aaent ana agree to conform to all aoDlicabfe laws of this iunsdiction.
Signature of applicant Add Ko�7� Don owe
dvvru o
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building use Grua
Permit issued 19_
Fire Grading
Building
Permit Fee $ Live Loading
Certificate of Occupancy $ O=Pawv Load
Approved by*.
Drain Tile $
Plan Review Fee $ �✓:1� r� ✓lam.
NOTES AND Data •(For department use)
t
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R
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by Comoleted by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD `
SIDE YARD SIDE YARD
_ - 9
REAR YARD
NOTES Q�
4
I
SITE OR PLOT PLAN -For Applicant Use
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ROM : DUFFY INSURANCE AGENCY INC PHONE NO. : 781 593 7260 Jan. 06 2005 12:39PN P1
dCOOOOO� CERTIFICATE OF LIABILITY INSURANCE T
MMOO YYY)
PRODUCER (781)593-1200 FAX (781)593-7260 202005
THIS CERTIFICATE IS ISSUED AS A MATTEATION
Duffy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THTE
317 Broadway HOLDER.THIS CERTIFICATE DOES NOT AMD OR
Wyoma Square ALTER THE COVERAGE AFFORDED BY THEELOW.
Lynn, MA 01 904-2602 INSURERS AFFORDING COVERAGE kINSURED Rektech I nCINSURER196 Haynes RoadINSURERS: Pilgrim Insurance Company5Sudbury, MA 01776 INSURER0: Travelers Insurance Com an6
INSURER 0:
IN6URER E
COVE S
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY aE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPB OP INSURANCE POUIY NUMBER POLICY EFFECsrvr: POLICY EXPIRATION LIMITS
GENERAL LIAS14TY EACHOCCURRENCE T
COMMERCIAL GENERAL LIABILITY DAMAGE TO REHTW
6
CLAIMS MADE LIOCCUR MED EXP(A"arw pwaon) 5
PERSONAL S ADV INJURY 6
_ GENERAL AGGREGATE S
am AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/W AGG S
POUCY jEa 600
AUTOMOBILE LIABILITY PMC7194539 01/27/2004 01/27/2005 COMBINED SINGLE LIMIT $
ANY AUTO (Ea er 11
ALL OWNED AUTO$
BODILY INJURY 5
B X SCHEDULED AUTOS (Pwwmbbl 250,00
X HIREDAUTOS BODILY INJURY
X NON-0WNEDAUTOS (FPraP eRD
500,000
...... PROPERTY DAMAGE S
(PeracgaenU 250.000
GARAGELUIBWTY AUTO ONLY-EA ACCIDENT S
ANYAUTO OTHER THAN EAACC S
P
AUTO ONLY: AGO S
EXCESSAIMBREIJ.A LIABILITY EACH OCCURRENCE 6
OCCUR LCIAIMS MADE AGGREGATE b
4
DEDUCTIBLE S
RETENTION 5 $
WORKERS COMPENSATION AND 6KUB7402A34-3-04 04/08/2004 04/08/2005 X 11J OSTATV- OTH-
EMPLOYSIM UARLI'TY E.L.EACH ACCIDENT s 100,00
C ANY PROPRIETORMARTNER/EXECUTNE
OFFICERAYEMBER EXCLUDED? EL DISEASE-EA EMPLOY 5 100,00
Ifyes,describe Imder
SPECIAL PROVISIONS holes, 111,DISEASE-POLICY UMIT 15 500.000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VENICUS I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS
ontractor
CERTIFICATE HOLDER C
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Salem DAYS WRITTEN NOTICE TO THE CERTIFICA MOLDER NAMED TO THELEFT.
ATTN: Electrical Department BU MLURE TO MAIL SUCH NOTICE SMALL IMPO OBLIGATION OR LIABILITY
City Hall INDU NWEINSURER, RE A S.
Salem, MA 01970 P A
ACORD 26(2001/0$) FAX: (978)745-3018 OAC RD PORA ION1111