6 PLYMOUTH STREET - BUILDING INSPECTION �� � v c� T� �9Ti'f'�' t
Nost))—9 City of Salem Ward
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.
I. AT(LOCATION) OVA ZONING
DISTRICT
LOCATION "o.; s EET) f
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS LOTETI
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 Nonresidential
2 ❑ Addition(it residential,enter number of new 12 ® One family 18 ❑ Amusement,recreational
housing units added,if any,in part D,13) 19 E] Chruch,other religious
2lp�1 13 ❑ Two or more family-Enter number
3 Afleration(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
7 ❑ Foundation only 26 ❑ School,library,other educational
17 ❑ Other-Specify 27 ❑ Stores,mercantile
8.OWNERSHIP 28 ❑ Tanks,towers
8 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,
q �I machine shop,laundry building at hospital,elementary school,secondary school,college,
10. Cost of improvement .............1. parochial school,parking garage for department store,rental office building,office building
.......W.................... $ 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............X..........................................................
b. Plumbing.....................................
c. Heating,air conditioning.............................................
d. Other(elevator.etc.).....................................................
11. TOTAL COST OF IMPROVEMENT $
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 E] 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 elevatoO
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 stones ............................................................
49. Total square feet of Boor area, f
all BHas App
floors,based on exterior oval from Historical Commission been received
dimensions ..................._.................................................... for any structure over fifty(50)years? Yes_ No_
so. Total land area,sq.ft....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES
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_ No-%, (If yes,please enclose documentation from Hist Com.)
Conservation Area? Yes_ NJL (If yes, please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes_ Nom
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# OLE 0 I -7� Salem License#
Home Improvement Contractor# /O`f I�C1 9` 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.
1. -A � ["SAQ Y e I �(� �� , 0IA 70 711— n6S-
0w1 1e1 or
Lessee
2. G-yvo !- 2Y I S fT- S a, S[ot+
Contractor
Builder's
License No. 6 YU 3
3.
Architect or 3 1q
Engineer
I hereby certify that the proposed work is u orized by the owner of record and that I have been authorized by the owner to make this application
as his authorized agent and we r to orm to all applicable laws of this jurisdiction.
Signature o Icant Adds Application date
3J
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building �j/�/J� FOR DEPARTMENT USE ONLY
Permit number b 7
Building Use Group
Permit issued 19 Fire Grading
Building
Permit Fee $ f IP.t_i Live Loading
Certificate of Occupancy $ occupancy Load
Approved by:
Drain Tile $
Plan Review Fee $ {{
� oGn. l
TITLE
NOTES AND Data •(For department use)
�9 t
PERMIT TO BE MAILED TO:
DATE MAILED: V ,9
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
u to appro y cum other
-7 having jurisdiction.
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