11 ADAMS STREET - BUILDING JACKET 11 Adams St.
No./-? of Salem Ward
A
/ APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all items in sections:1, It, III, IV, and IX.
ZONING
I. AT(LOCATION) N IdNH S'5 DISTRICT
LOCATION (" 'I/ (1 (STREET)
OF BETWEEN becerY KYCX 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 One family 18 ❑ Amusement,recreational
Musing units added,if 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
21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory-
Enter number of units ........................... 22 E] Service station,repair garage
5 ❑ Wrecking(K muttAamily residenfial,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 17 ❑ Other Specrty 26 ❑ School,library,other educational
27 ❑ Stores,mercantile
B.OWNERSHIP 28 ❑ Tanks,towers
8Private(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,
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 ......................................................... $ p019 at industrial plant If use of existinilding is being cha ed,enter proposed use.
To be installed but not included
in the above cost e—, �rg 0-9, np t-r-
a. Electrical ................ `_ - o ,• ``
b. Plumbing.._......................................................................
c. Heating,air conditioning.............................................
it. Other(elevator,etc.).....................................................
11. TOTAL COST OF IMPROVEMENT $ rJ�FJ,
111. 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 elevatoil
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:
ae. Number of stories .......
as. Total squors,based of exor terior Has Approval from Historical Commission been received
all floors,based o f exterior
dimensions ......................................................................... for any structure over fifty(50)years? Yes_ No_
50. Total land area,sq.ft. ................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed.............................................................................
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
sz. outdoors............................................................................. Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed............................................................................. Electric:
Gas:
54. Number of Foe.....................................:..... 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_ 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 # 03 15 Salem License # /-�x�y
Home Improvement Contractor # ll o'2 6.57f 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.
mlc-kyo E , o 3a
V. IDENTIFICATION • To be completed by all applicants
Name Mailing address-Number,street,city,and state ZIP Code Tel.No.
Owner or
S S4�Y,1
Lessee A x�
Contractor
Builders
0Q,, ^� J)., License No.
3.
Architect or bihetNcnL J uC I- 5 i
Engineer —WSfl
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.
f I' nt /,p Address Appl' tion ate
Signature o
'{ .2 s 3
aAk� c
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building j� / FOR DEPARTMENT USE ONLY
Permit number 7
Buildinga �j Use Group
Permit issued G 19L•L Fire Grading
Building
Permit Fee $ nC �f Live Loading
Certificate of OccupancyA
$ Occupancy Load
pproved by:
Drain Tile
Plan Review Fee $ / r�
ITL
NOTES AND Data• (For department use)
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
t
b
�U
O N �r
O
COMMONWEALTH OF MASSACHUSETTS
F� DEPARTMENT OF I.NDUSTRLAL ACCIDENTS
�� 600 WASHINGTON STREET
fames..' camooen BOSTON, MASSACHUSETTS 02111
_c. rm,ss,one, WORKERS' COMPENSATION INSURANCE AFFIDAVIT
(licensee/perminee)
with a principal place of gbusiness`/residence at:
�G( S l�csln�v� 1 5� f Ll9aAT-If5 \I-- )Mc, c;3 �
(City/State/Zi )
do hereby certify, under the pains and penalties of perjury, that:
'II am an employer providing the following workers' compensation coverage for my employees working on this
lob.
L, � *\,A
Insurance C mpany Policy Number
( ] I am a sole proprietor and have no one working for mc.
( J I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
who have the following workers' compensation insurance policies:
Name of Contractor Insuranc Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
[] 1 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 in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL. C. 152,sea. 10)), application by a homeowner for a license
or permit may evidence the legal stams of an 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 required 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 penalties in the form of a Stop Work Order and a
fine of S100.00 a day against me. ' /
Signed this c� f� day of IQr 1 l 119 !c�
3
Lic see/Permi Licensor/Permittor
Wawa,
(964=41" OAGO0 Arm A
- y :.�e�afio��s aaa,�lawaarna�s
Michaele Dukakis .{�C( a�wraaAe >t'afs ��,Out
Governor Jlcom lJOf
Kentaro Tsutsumt Aisd&m, .. amaovssrrs 02>08
Chairman
t617) 7Z7-.
Charies J. Dfneao
Administrator
MEMORANDUM
TO: All Buildine Departments6tatc Building Inspectors
FROM: Charles J. Dineao. Administrator
DATE. October 31. 1788
SUBJECT: Mr.l. can, ti54. Added Xv e594. 19 M the Acts of 19X7
The above-mcntionca statute rcgwris that debris resulting Irom the demolition. renovation, rehabilitation
or other alteration of a building or Structure he disposed of in a property liccriscd solid waste disposal
tacility as defined by MGL el 11. 5150A anu that building permits or licenses arc to Indicate the location
f the tacilliv at which the said dchns is to he disposed. THIS REOUIREMENT DOES NOT
,APPLY TO NEW CONSTRUC710N.
In order to simottfv the process and to provide unifofmtty, we arc attaching a copy cal a Corm which you
can either reproduce and use as it Is since the completed form will be attached to the Mice copy of budding
permits or licenses: or reproriuce at on your letterhead.
In circ of municipal.commercial.industrial,or multi-unit housing construction. the contractor may not know
the dumpster subcontractor at the time of the budding permit application. in such curs. the attached copy
of an Affidavit can be used.
The complete law is contained in the Novemner issue of CODEWORD which will be traded to von in the
next two weeks. If you should have any question, please let us know.
CJDlkm
In accordance with the provisions of MGL c 40, S 54, a condition. of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S
150A.
The debris will be disposed of in:
(Location of Facility) >
ignature of&drmit A plicant
y/mss-/9 3
Date
AFFIDAVIT
As a result of the provisions of MGL c 40, 554, I acknowledge that as a condition of Building Permit
Number all debris resulting from the construction activity governed by this
Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL
c 111, S 150A.
I certify that I will notify the Building Official by
(Two months maximum) of the location of the solid waste disposal facility where the debris resulting from
the said construction activity shall be disposed of, and I shall submit the appropriate form for attachment
to the Building Permit.
Date Signature of Permit Applicant
(Print or type the following information)
Name of Permit Applicant
Firm Name, if any
Address
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