9 SURREY ROAD - BUILDING INSPECTION 9 SURREY RC.
t
Nm,q6;1-53 City Of Salem Ward
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT X.
�NT-Applicant to complete all items in sections:1, 11, lll, IV,and I
I.
AT(LOCATION) -/ J (�Y✓P- L R� DISTRICT
LOCATION NOj (STREET)
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS ET)
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 ❑ Atltlglon(if residential,enter number of new 12 family 18 ❑ Amusement,recreational
housing units added,it any,in part D,13) 19 ❑ Chruch,other religious
13 ❑ Two or more family-Enter number
3 ❑ Alteration fSee 2 above) of units ....................................................... 20 ❑ Industrial
21 ❑ Parking garage
4 Repair replacement 14 ❑ Transient hotel,motel,or dormitory-
Enter number of units 22 ❑ Service station,repair garage
5 ❑ Wrecking(b mung in P residential,enter number 23 ❑ Hospital,institutional
of units in building n 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-SpecHy 27 ❑ Stores,mercantile
B.OWNERSHIP 28 ❑ Tanks,tourers
B Q Private(individual,corporation,nonprofit
i 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 -
a. Electrical...........................................................................
b. Plumbing..........................................................................
c. Heating,air conditioning.............................................
d. Other(elevator.etc.).....................................................
11.TOTAL COST OF IMPROVEMENT s '3100.-
III.
3 DO.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 elevato(1
34 Other-S 39 Other-Specify 42 ❑ Public or private company
❑ Specify ❑ Y A. ..__ :. 46 ❑ Yes 47 ❑ No
Private
( - ,
43 ❑ Private(well,cistern)
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
da. Number of stories ............................................................
49. Total square feet of floor area, Has Approval from Historical Commission been received
all floors,re fast
on ficar r pp
dimensions ......................................................................... for any structure over fifty(50)years? Yes_ No
50. Total land area sq.It....................................................... 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 Partial DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
"""""""""."""""'."""' BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No Z (If yes,please enclose documentation from Hist. Com.)
Conservation Area? Yes_ No✓ (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�'z/N Salem License # Z LE-3
Home Improvement Contractor # /D.3 6 S e? 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 019?�o 3 1�37 —
Lessae ' N
o/c/ 71j
z.
Contractor Builders C)
Builders
.S License No. C
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 conform to all applicable laws of this jurisdiction.
Signature of applicant Address Application date
4 e7� v v 3
E
DO NOT WRITE BELOW THIS LINE
VL VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
- Use Group ,
Building ✓ 6 7 — �3
Permit issued ig -- Fire Grading
Building
Permit fee $�-� -� D Live Loading
OCCWaancy load _...--._
Certificate of Occupancy $ Approved by:
Drain Tile $
Plan Review Fee , $ a
TIT
NOTES AND Data•(For department use)
Dk b _ eel
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PERMIT TO BE MAILED TO: Qt..t/ /.-
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