16-18 SCOTIA STREET - BUILDING INSPECTION (2) 617-
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No. g City of Salem Ward
01
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APPLICATION
_ FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTAMT-Applicant to complete all items in sections:1, ll, 111, IV, and 1X.
--L� 'Sib ZONING
I. AT(LOCATION) DISTRICT
LOCATION (STFPV
t
OF BETWEEN ` y �/)\ +V AND
BUILDING LOT(CROSSSTREET)
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
1 ❑ New building Residential Nonresidential
2 J;Addition(If residential,enter number of new 12 One family 18 ❑ Amusement,recreational
housing units added,it any,in part D,13) 19 ❑ Chmch,other religious
13 ❑ Two or more family-Enter number
3 ❑ Alteration(See 2 above) of units ....................................................... 20 ❑ Industrial
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- 21 El Parking garage
Enter number of units ...........................
22 ❑ Service station,repair garage
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 [j Foundation only 17 ❑ Other Specify 26 ❑ School,library,other educational
27 ❑ Stores,mercantile
B.OWNERSHIP
Private individual,co 28 E] Tanks,towers
8
( corporation,nonprofit
institution,etc.) 29 ❑ Other-SpecAy
9 ❑ Public(Federal,State,or local government
C.COST - (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant,
.p ..- $ machine shop,laundry building at hospital,elementary school,secondary school,college,
10. Cost of improvement ...... Q .Q�!O ecoparochial school,parking garage for department store,rental office building,office building
"'1I .................. ' 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.............................................i............................
.
b. Plumbing..........................................................................
c. Heating,air conditioning..............................-.............
d. Other(elevator,etc.)..................................................... ---..
11. TOTAL COST OF IMPROVEMENT $
111. SELECTED CHARACTERISTICS OF BU DING -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 W Public or private company Will there be central air
31 Wood frame 36 ❑ Oilconditioning?
41 E] Private(septic tank,etc.)
32 ❑ Structural steel 37 ❑ Electricity 44 ❑ Yes 45 �No
33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an ekwatoR
34 ❑ Other-Specify 39 ❑ Other-Specify 42 Public or private company
46 ❑ Vas 47 5rN0
43 ❑ Private(well,cistem)
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48. Number of stories ............................................................ _
49. Total square feet of floor area
all floors,based on exterior �7 Q-� Has Approval from Historical Commission been received
dimensions ..................--............-.................................... L O for any structure over fifty(50)years? Yes_ No
50. Total land area,sq.ff.-.................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES
SL Enclosed........... ..................... Pest Control:
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. Outdoors.......................... ........... Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
-53. Enclosed'............................................................................. Electric:
Gas:
.
54. Number of FullSewer:
bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Pallial......_.--------............ 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_z (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 # 0 Q Salem License#
Home Improvement Contractor# ,o5ngl 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.
So b l e lqd
Owner or
Lessee
2. CLOW le. �Is.Cr Gl q
Contractor
Builder's
Yr Q v W.-q,ti License No.
3. SA w
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 a ent and we agree to conform to all applicable laws of this jurisdiction.
Sign a appli Addres�G Application date
l O � Gll
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 $ Live Loading
Certificate of Occupancy $ Approved by Occupancy Load
Drain Tile $
Plan Review Fee $
TITLE
NOTES AND Data• (For department use)
16 '
/
luco Aleut) Ire)
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
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