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No.—Ayf- V City of Salem Ward _
x
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete
ro�m�plle�t ye1all items in sections:1, 11, 11111,, II�V, and
�IX.
I. AT(LOCATION) / D U 1 1—yy`� IG /�_I�Irr / DISTRICT
LOCATION (NO.) s TEE l
OF BETWEEN V I PT ' e- '
BUILDING (CROSS STREET T (CROSS ETI
LOT
SUBDIVISION 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
V'1 ❑ New building Residential Nonresidential
2 ❑ Addition(U residential,enter number of new 12 ❑ One family 18 ❑ Amusement,recreational
housing units added,if any,in part D,13) 19 ❑ Chruch,other religious
13 ❑ Two or more family-Enter number
3 Akeration(See 2 above) of units ..................................... . ............ 20 F]El21 ElParking garage
❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory-
Enter number of units 22 E] Servicestation,repair garage
5 ❑ Wrecking(if muttNamily residential,enter number 23 ❑ Hospital,institutional
o/units in building in Part D, 13) 15 ❑ Garage
24 E] 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.OWOIERSHIP _ 28 ❑ Tanks,towers
8 Private(individual,corporation,nonprofit ` y 1 29 [:] Other-Specify
institution,etc.)
9 Public Federal,State,or local � R
❑ ( 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,
10. Cost of improvement ......................................................... $ parochial school,parking garage for department store,rental office building,office building
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...........................................................................
b. Plumbing..........................................................................
c. Heating,air conditioning.............................................
d. Other(elevator,etc.)....................................................
.
11. TOTAL COST OF IMPROVEMENT $,;(40 r
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 ............................................................
49. Total square feet at floor area,
all floors,based on exterior Has Approval from Historical Commission been received
dimensions ......................................................................... for any structure over fifty(50)years? Yes_ No_
50. Total land area,sq.n....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed ............................. ...
sz. 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_ No (If yes, please enclose documentation from Hist. Com.)
Conservation Area? Yes_ N07>� (If yes,please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes A 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 # 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,street,city,and state ZIP Code Tel.No.
Owner or
0/97 5- 7s
Lessee
2.
Contractor
Builders
License No.No.
3.
Architect or
Engineer
I hereby c ify 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 hOnzed agent and we agree to conform to all applicable laws of this jurisdiction.
Signat e o' pplAdd, - A
pplication date
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building use Group
Permit issued 19 ?,5
• Fire Grading
Building /�
Permit Fee $ ac , 17 0 Live Loading
Certificate of Occupancy $ Approved by: Occupancy Load
Drain Tile $
Plan Review Fee
L TITLE
NOTES AND Data •(For department use)
Yn -YV1,
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by: Completed by:
C
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