Loading...
123 1/2 BOSTON STREET - BUILDING JACKET 123 1/2 Boston St. - t No. 153L-2 HASTINGS. MN LOS ANGELES-CHICAGO•LOGAN.ON MCGREGOR.TX•LOCUST GROVE.GA U.S.A. Ti %"ROOM 1 it C 4 ---�X -- _ 1 Oa ; --- _ - 1 '. , ..... . - 1 sv�w A ., ar�c�1N6 iS TAE ' IVEw RDD1Y�pN� r2E11+ovE RLL EXKT111G 010bows XN8 FLOOD SCALE . i/4 - o PND QC-PLP-ce W(-rA Ne-Lx) PERMa-SWtLb w1unew$ NEW -%RsfAWMw,,. A(tVVNA.+` (.)Nb oov p s, AL'so NewOOLLOW 0094x. S��b� I fhgS� , NoV7 .8 City of Salem Ward 4cuo"c� 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) 42A Go S l O N S ZONINGT "tea LOCATION "o.) s REEn OF BETWEEN AND BUILDING (CROSSSTREET) (CROSS STREET) 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 housing units added,if any,in part D,13) 19 ❑ Chruch,other religious 13Y Two or more family-Enter number 3 ❑ Alteration(See 2 above) of units....................................................... 20 ❑ Industrial /// 21 E] Parking garage 4,,,,,,--- Repair replacement 14 E] Transient hotel,motel,or dormitory- Enter number olunits ........................... 22 E] 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 ❑ Foundation only 26 ❑ School,library,other educational 17 ❑ Other-Specify 27 ❑ Stores,mercantile B.OWNERSHIP 28 ❑ Tanks,towers 8 ❑ Private(individual,corporation,nonprofit 29 E] Other-Specifyinstitution,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, 10. Cost of improvement ......................................................... $ parochial school,parking garage for department store,rental office building,office building 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........................................................................... It. Plumbing.......................................................................... c. Heating,air conditioning............................................. d. Other(elevator,etc.)..................................................... 11. TOTAL COST OF IMPROVEMENT 1, , QQO 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 1. TYPE OF MECHANICAL 30 ❑ Masonry(wall bearing) 35 ❑ Gas 40 ❑ 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 elevator7 34 ❑ Other-Specify 39 ❑ Other-Specify 42 ❑ Public or private company 46 ❑ Ves 47 ❑ No 43 ❑ Private(well,cistern) J.DIMENSIONS M. DEMOLITION OF STRUCTURES: 48. Number of Stories .............................. loor 49. Total ors,based on exterior arefor Has Approval from Historical Commission been received all floors,re feet on exterior 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............ ....................... HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? sz. Outdoors............................................ Yes No L RESIDENTIAL BUILDINGS ONLY Water: 53. Enclosed............................................................................. Electric: Gas: 54. Number of Full.................. Sewer: - bathrooms PaDOCUMENTATION 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 documentationff 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# Salem License# Home Improvement Contractor # Homeowners Exempt form (if applicable) Yes_ No CONSTRUCTION TO BE COMMENCED WITHIN SIX (6)MONTHS OF ISSUANCE OF BUILDING PERMIT CONSTRUCTION IS TO BE COMPLETED BY: If an extension is necessary, please submit 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 - �) ® `� C& / Vn`q7O Lessee 2. Contractor Builder's License No. 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. Signat a of ant Address Application date OtL4 IA A4 _ O!C/ oS DO NOT WRITE BELOW THIS LINE VI. VALIDATION h Building //� 7 SCJ S FOR DEPARTMENT USE ONLY Permit number `/ / ✓J Building (� LI Use Group Permit issued j422 19 Fire Grading Building �//� tt� Permit Fee $ 7 ,C� Live Loading Certificate of Occupancy $ Approved by: Occupancy Load Drain Tile Plan Review Fee $ TITLE NOTES AND Data-(For department use) A-C ^Mb 6 CKJ, S, DOo S o C JQ E"j Cr4 9C-- �tiT�ivG VS Grew I o ev u4F- PERMIT TO BE MAILED TO: DATE MAILED: �7 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 ON : ot ^, The Commonwealth of Massachusetts Department of Public Safety '�.. f .Xlassachusetls State Building Code(780 C:Y1R)Seventh Edition City of Salem Buildin Permit Application for any Building other than a 1-or 2-Family Dwellin (This Section For Official Use Onl Building Permit Number: Date Applied: B ik ng Inspector SECTION 1: LOCATION(Please indicate Block# and Lot# for locati ns a t et addres t available) _12 '> & 9M70tn 5 r 5A(C-4A IMR OfQ O ,l No.and Street Citc /Town Zip Code Name of Building(if applicable) SECTION 2: PROPOSED W If New Construction check here O or check'all thafapply in the two rows below Existing Building❑ Repair❑ Alterations Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ Note^- Brief Description of Proposed Work: — IC rrk lti d no4 S14 00 tO 7w, cIG i,- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): r Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No,of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) - SECTION 5:USE GROUP(Check as applicable) _ A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1.0 H-2❑ - H-3 ❑ H-4❑ H-5❑ L• Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-i❑ R-2❑ R-3❑ R-4❑ S: Storage 571 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a plicable) IA ❑ IB ❑ IIA ❑ 11B ❑ IIIA ❑ 111B ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Trench Permit: Debris Removal: Publics Check if outside Flood Zone Indicate municipal-bl A trench will not be Licensed Disposal tiite� Private❑ or indentifv Zone: or on site system ❑ required W"r trench or specify:in,Ovtl4 5It'>E— permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: E1:\ I li1:pri.(lann:i"i:m R'ov i„• 1'r......1: \nt Applicable 1>Structure within airport approadt areal Is then'rev iew completed, "n'C:msenl l0 14111d endo.ed ❑ Yes❑ or No k 1'es❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Ldilion of Code: Use Gtouplsl: Type of Construction: Occupant Lund per Fluor- D) wa the building;containan Sprinkler Stslem?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of property Owner _A ton EW?v 0 C41 ve P a vP Name(Print) Nu.and Street City/Town Zip Properly Owner Contact Information: 1�a q* 7y0 2 �oJ�Q Title Telephone No. (business) Telephone No. (cell) e-mail address If applica ale, the property"owner he irizes C4 e;-cicy a✓e Name Street Address City/Town Stale Zip to act on the pnr pert%owner's behalf, in all matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (if building is less than 35,000 nr,ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section M I) 10.1 Registered Professional Responsible for Construction Control da eat. ql��g 6Z�y CS 7 © R traryt) /' Teleone t. � }v e-mail address l Registration Number Name a ros �� C(ov�ro� ph SQ PU/1 O �119 l- S Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 1/I k dl Cam[. V V , 11A Company Na C S 7 0 ( / Name of Person Respon li fur Cons-tcr.�Jyctiu /I License/No. and Type if Applicable C) C3 v P t'ct ClY C S aka—n�r Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No I] SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 00 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ 00 appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) 5. Mechanical (Other) S Enclose check payable to c ll.•`\) 6.Total Cost $ C?o 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalti s of perjury t t a e information contained in this application is true and accurate to the best of my knowledge and and tt iing. Please print and gig name• / / Title Telephone No. Date d C O t/Q tro( mil% S — © Q titreet Addre nn / Cih/Toren State Zip Municipal Inspector to fill out this section upon application approval: �""•""' /� /V Name Date