12 DERBY SQUARE - BUILDING INSPECTION JACKET 12 DERBY SQUARE j ' • ^
1
No. 9� _94/ City of Salem Ward
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APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all items in sections:1, 11, 111, IV, and IX-
ZONING s
I. AT(LOCATION) yy 7�—r (STREET) - .
OF BETWEEN
BETWEEN ^ S( t AND (�gUNr s7`T DISTRICT
r
(CROSS STREET) (CROSS STREET)
BUILDING LOT
SUBDIVISION /f LOT BLOCK SIZE
11. 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 Reeldsntial Nonresidential
2 ❑ Addition(It residential,enter number of new 12 ❑ One family 18 ❑ Amusement,recreational
housing units added,Aany,in part D,13) 19 ❑ Chruch,other religious
13 El Two Or more Family-Enter number
3 ® Alteration(See 2 above) of units ......................_............................... 20 ❑ industrial
21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- 22 ❑ Service station,repair garage
Enter number of units ...........................
5 ❑ Wrecking(II multifamily residential,enter number 23 ❑ Hospaal,institutional
of units in buiMing in Pan 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-Specify
institution,etc.)
9 ❑ Public(Federal,State,or local govemment
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
�0. Cost of improvement .......
`"-"""" $ 5 6" at industrial plant.If use of,7existing building is being Changed,enter proposed use.
Tobe installed but not included4V d r//
a.athe above cost / 0 O �\ f
Electrical..........................................................................
b. Plumbing....................................................._._.............. /� D //n �/ `�'✓� / 'L✓U"'�
C. Heating,air Conditioning..........................._................ /""lirr�f DY ✓l'1/'U'
d. Other(elevator,etc.)............................_.............
......._.Fs5,
11. TOTAL COST OF IMPROVEMENT .✓ S EOO
III. 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. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL I. TYPE OF MECHANICAL
30 ❑ Masonry(wall bearing) 35 ❑ Gas 40 ❑ Public or private Company Will there be Central air
31 ❑ Wood frame 36 ❑ Oil 41 ❑ Private(septic tank,etc.) conditioning?
32 ❑ Structural steel 37 ❑ Electricity 44 ❑ yes 45 ❑ No
33 ❑ Reinforced Concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an elevator?
34 ❑ Other-Specify 39 ❑ Other-Specify 42 ❑ Public or private Company 46 ❑ Yes 47 ❑ No
43 ❑ Private(well,cistern)
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48. Number of stories ............................................................
as. Totalrs,re bash on exterior feet of poor area,
all floors,baHas Approval from Historical Commission been received
dimensions ........................................................................ for any structure over fifty(50)years? Yes_ No_
50. Total land area,sc.It....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES
51. Enclosed.......... ..............._...._..._.................................. Pest Control:
52. Outdoors
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed............................................................................ Electric:
Gas:
Full..... ......... Sewer:
54. Number of
bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Partial...................................... BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:��//
Historic District? Yes_ Nom (If yes,please enclose documentation from Hist. Com.)
Conservation Area? Yes_ No-XI (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? Yes24 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_ A11>1--
Is
lIs Architectural Access Board approval required? Yes_ No-K (If yes,submit documentation)
Massachusetts State Contractor License*�O.�2–;2e�d'd 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: — 95 in writing to the Inspector of Buildings.
V. IDENTIFICATION • To be completed by all applicants
Name Mailing address-Number,street,city,and state ZIP Code T•ell..No.
Owner or
Lessee
2.
Contractor Irg— / l ri�% JJ a •O.�/b
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 co orm to all applicable laws of this jurisdiction.
Sig nt Address Appligatign date
�V
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issued 19 Fire Grading
Building
Permit Fee $ 5 . Live Loading
Certificate of Occupancy $ Approved b Occupancy Load
Drain Tile $ __
Plan Review Fee $
T L '
NOTES AND Data - (For department use)
J
/It
PERMIT TO BE MAILED TO: l 0
DATE MAILED:
Construction to be started by: /2 Completed by: