29 WINTER ISLAND ROAD - BUILDING INSPECTION 29. Winter Island Rd.
No. 7-� City of Salem Ward I
��.LWTYt1.
�CLW1n Od
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to completeanitems in sections:1, It, ill, IV,and IX.
P9 9 &)//J / C 'i w rA ZONING
I. AT(LOCATION) uo.) ���'I���s EI —� C DISTRICT
LOCATION
OF BETWEEN AND
BUILDING (CROSS STREET) )CROSS ET)
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 " Nonresidential
2 ❑ Addition(If residential,enter number of new 12 & ne 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 ❑ Alteration(See 2 above) of units....................................................... 20 ❑ Industrial
21 ❑ Parking garage
4 �epair replacement 14 ❑ Transient hotel,motel,or dormitory-
22 ❑ Service station,repair garage5 E] Wracking(fl muMifamily resldEnter number of units ...........................ential,enter number 23 ❑ Hospital,institutions
E] l
of units in building in Part D,13) 15 Garage
- 24 ❑ Office,bank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
26 E] School,library,other educational
7 ❑ Foundation only 17 ❑ Other-Specity
27 ❑ Stores,mercantile
B.OWNEIjSHIP 28 ❑ Tanks,towers
8 Lr1�d/Private(individual,corporation,noriprofit
institution,etc.) 29 ❑ Other-Specify
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 $
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 of floor area, pp r
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.It....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed.............................................................................
II,
52. 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—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—Z 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—Z (If yes, submit documentation)
Massachusetts State Contractor License # n a Fy y Salem License#
Home Improvement Contractor# a, 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.
QlAilr d9rrd 05, 2 fevl s�4ktRh, rrv. _� �/ OG
Owner or -
Lessee
Contractor
G Builder's
License No. 1 0,200',9(15
3.
Architect or u
Engineer Y
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 /' Addressry Ap licati n date
Y en / a
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building G/'� FOR DEPARTMENT USE ONLY
Permit number /
Building �CJJ,QQ� use Group
Permit issued 19_�
Fire Grading
Building `^/(
Permit Fee $ `-�v p�� Live Loading
Certificate of Occupancy $ Occupancy Load
Approved by:
Drain Tile $
Plan Review Fee $
TITLE
NOTES AND Data-(For department use)
e- R-
2
IU e'A) 1
PERMIT TO BE MAILED TO: � ,1
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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SaZem Fil=_ Depcvr tmvr+L
Fvice Pieeventton Bureau `.
48 La4ayette Street
Salem. Mm 01970
(508) 745-7777 t
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT
In accordance w<th the P40V464on,a o¢ the Ma.66acJw,6ett4 State Bu i.Qr _;' Code
and the Sateen FZ-ae Code, appX i.catton 46 heaeby made 4o2 appnovaZ 06 pt rr4
and #Jae .i.4a1'ance 04 a eeAt 4tcate 04 approvaC 40t a buiZdin9 pe-,=t by the
SaZem Fire Department. (Re4. Section 113. 3, Ma.64. State BZdy. Code)
Job Lvcati on: l . '��yL L �� ,� QZ
Owner/Aeempomt:EZect.ttca.E Conttacton.: I7 In
F:,te Suppt".6 on Cont%actot:
Sdgnatu4e 04
APpZteant: Phone #: (0 ,-ST/� `22Gf
Addne" o4City of
Appt,Lcant: S� /10 la/C/�a ! 7`. Town:
�L
ApptovaZ date
Centt44.ieate 04 appn.ova 44 hereby granted, on approved pZa.n4 on. 6ubm-itt
o4 ptoject deta424, by the SaZem F4, a Department. AZC pZanb ane approved
40Zeey 4ot tdent444za 4on o4 type and Zocati.on 04 4-1,te P40tectton dev.tce4
and equipment. AZZ Pt=6 ate 4ubjeet to apptovae 04 any othet autho4wty
hay.cng ju4 i.6dtctr on. ' 'Upon compZe t Lon, the appt4xant on dn4ta to t(4) 4ha t
4eque.6t an Ln bpec t ton and/ot te4t .o4 the 44,te per otec t.Lon dev-4ce4 and
equ,tpment. FOR ADDITIONAL REQUIREMENTS, SEE REVERSE SIDE
0 New con4t4uet.Lon.
Ptopenty Zocat.Lon ha4 no comp2.4ance w4th the ptovt-6.torw 04
Chapter 148, Seetton 16 C/E, M.G. L. , teeative to the
Zn4taZa t Lon o4 approved 44, a alarm, dev.i ce.6. The owner o4
thZ4 ptopetty 46 tequ44,ed to obtain compZtance a4 a
condi t.Lon 04 obtatn.4nq a Bu t2diny Perm-t.
Ptopearty Zocat on 'Z4 do compt ance with the ptov4,a.ton4 04
Elp Chapter 148, SectZon 16 C/E, M.G.L.
Exp44vtlon date: „II/
Fee due: under 7 , 500 Sq. Ft.
7 . 500 So . Ft. 4 00 BRl (PPL, tn !cn )
i. v: .'...$ ✓ t:ix w'. h6rm. a,^.Tr ��_
y,..�+ +'F�
FIRE DEPARTMENT CERTIFICATE OF 4PPROVAL FOR BUILDING PERMIT ` tMs+
In compliance with the provision of Section 213.5 of .the Massachusetts
State Building Code, and under '
guidelines agreed upon by the Salem Bldg.
Inspector and the Salem Fire Chief, the applicant for a building permit
shall obtain the Certificate of Approval (see reverse side) and stamped
plan approval from the Salem Fire Prevention Bureau. ,: 0.
Said application and approval is required before s building permit may be ..
issued. The Massachusetts State Building Code requires compliance
approval of the Salem Fire Department, with.reference to provisions of
Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts
General Laws, and 527 Code of Massachusetts Regulations.
' The applicant shall submit this application with three (3) sets of plans,
drawn in sufficient clarity, to obtain stamped approval of the Salem Fire
Department. This applies for all new construction, substantial
alterations, change of use and/or occupancy, and any other approvals
required by the Massachusetts General Laws, and the Salem Fire Code. ,
- Exception: Plans will not be required for. structural work when the
proposed work to be performed under the building permit
n2t, in the opinion of the Building Inspector,. require be"',
_ "r�......
plan to show the nature and character of the work to be , ;nom
performed.
Notice: Plans are normally required for fire. suppression„systems,
fire alarm systems, -tank installations, and Fire Code
requirements.
r
Under the provisions of Article 22 of the Massachusetts State Building
Code, certain proposed projects may not.- require- submission of plans or
complete compliance with new construction requirements. .'.rn`these ter.
cases, provisions of Article 22, Appendix Ts:'and Tables applicable
shall apply: �.Thia section shall not, however -supersede. the"
provisions outlined in the Salem Fire'. Prevention Regalations "'Chapter
1489 MGL, or 527 Code of Massachusetts: Regul'ations. "All.permits for
fire code use and/or occupancy shall apply for-the entire structure; �%
fire alarm and/or smoke detector installation'shall apply to the
entire structure based upon current requirements as per Lain and/or
Codes, but the existing structure
may comply 'wi"th regulations
applicable for existing structures.
Notice: Sub-contractors may also be required to file individual
applications for a Fire Department- Certificate of. Approval•
for the area of their work.. Such sub-contractors shall file
an Application to Install with the Fire prevention Bureau
prior to commencing any work for those areas applicable.
Form 81% (10/90)
COMMONWEALTH OF MASSACHUSETTS
`c? ;SEI`AR."MENT OF PVDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
BOSTON, MASSACHUSETTS 02111
aures Canooen
�m�•ss one WORKERS, COMPENSATION INSURANCE AFFIDAVIT
(IicensetioermitteU
with a principal place of business/residence at:
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that:
�am an employer providing the following workers' compensation coverage for my employees working on this
iob.
C3,5,22 5 ff 9�
Insuran Company Polity Number
� ) I am a sole proprietor and have no one working for me.
I
a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
I1 P P
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name or Contractor Insurance Companv/Policy Number
Name of Contractor Insurance Companv/Policy Number
(]. I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance.construction or repair work on a
dwelling of not more than three units to which the homeowner aim resides or on the grounds appurtenant thereto in not generally
considered to be employers under the Workers' Compensation Act(GL C. 152.sect. 1(5)),application by a homeowner for a license
or permit may evidence the legal sums of m employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage
verification and that failure to secure coverage as repuired under Section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to $1500.00 and/or imprisonment of up to one year and civil penaitics in the form of a Stop Work Order and a
fine of S 100.00 day against me.
Signed this rn day of 19 9'/
Licensees Permirree licensor/Permittor