8 HATHORNE PLACE - BUILDING INSPECTION 8 Hathorne Place.
F '
VA
No. )U City of Salem as Ward v
3 b
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all items in sections:1, Il, 111, IV, and IX.
ZONING
I. AT(LOCATION) _ DISTRICT
LOCATION L//I
OF BETWEEN 1/52 fA u�v �TYPi� AND
(CROSS SHEET) )CROSS STREET)
BUILDING LOT
SUBDIVISION LOT 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 Nomesidenttal
2 ❑ Addition(it residential,enter number of new 12 One family 18 ❑ Amusement,recreational
housing units added,it any,in part D,13) 19 ❑ Chn ich,other religious
13 ❑ 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(if multifamily residential,enter number 23 ❑ Hospital,institutional
of units in building in Part D,13) 15 ❑ Garage
24 ❑ Office,bank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
26 ❑ School,library,other educational
7 E] Foundation only 17 ❑ Other-Specify
27 ❑ Stores.mercantile
S.OWNERSHIP 28 ❑ Tanks,towers
8 Cal Private(individual,corporation,nonprofit 29 ❑ Other-Specify
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
aElectrical..............................................................._........ Qdsn- 7— Gacn��
b. Plumbing.........................................................__.._...._...
c. Heating.air conditioning.............................._._........
d. Other(elevator.etc.)......................................._..._......
11. TOTAL COST OF IMPROVEMENT $
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. 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 fame 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,cistem)
J,DIMENSIONS M. DEMOLITION OF STRUCTURES:
58. Number of stories ............................................................
ag. Totel square feet Of floor area Has Approval from Historical Commission been received
an floors,based on exienor
dimansiona ......................._.............................................,. for any structure over fifty(50)years? Yes— No_
$0. Total land area,sq.If....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed ...__.........._.............__................._................_
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. outdoors........_ ......... Yes NO
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed................._......_............... Electric:
Gas:
Full........................................... Sewer:
54. Number of
ba morons DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Partial......................-..........-.. BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No_ (If yes,please enclose documentation from Hist. Com.)
Conservation Area? Yes_ No_ (It 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 documentationfif 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# 17 414y/a Salem License# f OS 3
Home improvement Contractor# 1 0 Z e< �cf` Homeowners Exempt form(if applicable) Yes.. No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX (6) MONTHS OF ISSUANCE OF BUILDING PERMIT
CONSTRUCTION IS TO BE COMPLETED BY: If an extension is necessary,please submit
in writing to the Inspector of Buildings.
V. IDENTIFICATION • To be completed by ali applicants
Name Mailing address-Number,sbaet,city,and state( 7JP Code Tat.No.
14..1-e dzLo cc-
Oxmer or
Lessee
2.
Contractor Builder's
License N0,
3.
Architect or
Eng-au
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 a Address Appli'pation date
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
BuildingG�_ �Y FOR DEPARTMENT USE ONLY
Permit number CC))
Building Use Group
Permit issued t 0 I I 4 19_
Fire Grading
Building 26�
Permit Fee $ Live Loading
Certificate of Occupancy $ Approved by: Occupancy Load
Drain Tile $ n u��� o r✓
Plan Review Fee $ u
TITLE
NOTES AND Data-(For department use)
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by: Completed by:
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES ,
SITE OR PLOT PLAN •For Applicant Use
O N