32 CLARK STREET - BUILDING JACKET 32 Clark St.
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The Commonwealth of MassachuseMpECTIONAL SERVI EV,
4 Board of Building Regulations and Standards CITY OF
Massachusetts State BuildingCode 780 SALEM
VAN 13 A 11: 016vised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied
13 I
Building Official(Print Name) ,e,+;� ,� ,Signature `• ..- Date
SECTION 1; SITE INFORMATION
1.1 Property Add�ess: s� 1.2 Assessors Map&Parcel Numbers
1.laf Is this an Laccepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[ 's
2.1 Owner[of Record: m
ilAlFre".1-ic> w SAlei A&Lt55 vfq76
Name(Print) City,State,ZIP
39 ClatbC 5� 7ys=lll�/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) f
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': :5RC�p I q.f¢� flu�[ S�p� �1UI-
E r �!
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item ' Estimated Costs:
Labor and Materials Official Use Only +w"
t.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
.::
2.Electrical $ ❑Standard City/Town Application Fee +�
❑Total Project Cost'(Item 6)x multiplier :z -
3.Plumbing $ 2. Other Fees ;$ ,
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $ ._ Y- _•
B O Check'No `Check Amount: Cash Amount:
6.Total Project Cost: $ 0� ❑paid in Full a"<m ❑ Outstanding Balance Due:+
TA(a I L TU l• O . :, �s QO N•O. tp ( 11
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Oe pCSe U i St L 1 A M License Number Expiration Date
Name of CSt Holder
J List CSL Type(see below) t
.� ,
tS anG { „,,uT _``.� Descri lion
-_-_
Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) `)t
1S1CAsL?W k IWA 40M�NAL�- (( ��$, HIC Registration Number Expiration Date
HIS Company Name or HIC Registrant Name
No.and Street A Email address
ASrS7�s5f�
City/Town, State,ZIP ` Tele hone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT;
1,as Owner of the subject property,hereby authorize AkA," oKr, {
to act on my behalf,in all matters relative to work authorized by this building permit,_application.Arv1d L.IC ISIAR) C,//31//'I l
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION . r
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in th is application is true and accurate to the best of my knowledge and understanding.
sl/FiP� k K.4 V�2 b1,31iq
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES: _. . r '.
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
No. 7"�\ '�13. City of Salem Ward
A '9
X
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all items in sections:1, ll, 111, IV,and IX.
I. AT(LOCATION)
3A CLARK STREET DIISTRICT�
LOCATION (NO.) 1516EET1
l7EAD
OF BETWEEN 11/6<fAAI- dEA/UE AND
LL /1Eti D
BUILDING (CROSS STREET) (CROSS Loren
SUBDIVISION LOT Af BLOCK SIZE
II. TYPE AND COST OF BUILDING -All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION'USE MOST RECENT USE
1 ❑ New building Residential Nonresidential
2 ❑ Addition(It residential,enter number of new 12 ❑ One family 18 ❑ Amusement,recreational
housing units added,tt any,in part D,13) 19 ❑ Chruch,other religious
13 ❑ Two or more family-Enter number
3 ® Alteration(See 2 above) of units ....................................................... 20 ❑ Industrial
1 21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory-
Enter number of units ........................... 22 [:] Service station,repair garage
5 ❑ Wrecking(tt multifamily residential,enter number 23 E] Hospital,institutional
of units in building in Part D, 13) 15 ❑ Garage 24 ❑ Office,bank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
7 ❑ Foundation only 26 ❑ School,library,other educational
17 ❑ Other-Specify 27 ❑ Stores,mercantile
B.OWNERSHIP 28 ❑ Tanks,towers
8 ® Private(individual,corporation,nonprofit
29 ❑ Other-Specity
institution,etc.)
9 ❑ Public Federal,State,or local government
C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant,
machine shop,laundry building at hospital,elementary school,secondary school,college,
parochial school,parking garage for department store,rental office building,office building
10. Cost of improvement ......................................................... $ at industrial plant.If use of existing building is being changed,enter proposed use.
To be installed but not included
in the above cost
a. Electrical........................................................................... "
b. Plumbing..........................................................................
c. Heating,air conditioning.............................................
d. Other(elevator.etc.).....................................................
11. TOTAL COST OF IMPROVEMENT $ `-7 000
111. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L;demolition,
complete only Parts J& M, all others skip to IV
E. PR-_INCIP OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL I. TYPE OF MECHANICAL
30 ❑ Masonry(wall bearing) Gas 40 ® Public or private company Will there be central air
31 ® Wood frame ) 36 N Oil 41 ❑ Private(septic tank,etc.) conditioning?
32 F1Structural steel \\J// 37 ❑ Electricity 44 ❑ Yes 45 ® No
33 ❑ Reinforced concre 38 ❑ Coal H. TYPE SUPPLY Will there by an elevator?
34 C] Other-Specify 39 ❑ Other-Specify 42 ® Public or private compan Yes 47 No
43 ❑ Private(well,cistem)
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48. Number of stories ............................................................
49. Total square fast of floor extearea,exteri
all floors,basad on or
Has Approval from Historical Commission been received
dimensons ......................................................................... for any structure over fifty(50)years? Yes_ No_
50. Total land area,sq.ft....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed ....................................
52. Outdoors HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed ............................................................................. Electric:
Gas:
54. Number of Full........................................... Sewer:
bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Partial ........... BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ NoX— (If yes, please enclose documentation from Hist. Com.)
Conservation Area? Yes_ NoX— (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? Yes_ No_ (If no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No (If yes, submit documentation/if 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_ (If yes,submit documentation)
Massachusetts State Contractor License At Salem License#
Home Improvement Contractor# 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: in writing to the Inspector of Buildings.
V. IDENTIFICATION • To be completed by all applicants
Name Mailing address-Number,sheet,city,and state ZIP Code Tel.No.
1.Omer or A« ED LUC/AND 3.2 C'CllrP ST. S LE A 0/970 7115-//J Al
Lessee
2,
Contractor
Builder's
License No.
3.
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.
Signature of applicant Address ADolication date
3,� NA7,e1( ST SALE.'? NIA. 7 93
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issuedo94. -
Building � / / Fire Grading
Permit Fee $ � 0,-4 �FJ�� Live Loading
Certificate of Occupancy $ Occupancy Load
Approved by
Drain Tile $
Plan Review Fee $
oG
/ T E
NOTES AND Data-(For department use)
� 8
Vl 1 S C C„ O C
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m
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by: Completed by:
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VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN -For Applicant Use
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108.02,
7159 B
SHEET 3