1 & 3 COUSINS ST - BUILDING PERMIT APP No. 9 City of Salem Weal
a � 0
ry 9 \
ulld�_ 2 clllo APRUCATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR ?ONSTRUCTION
MIFORTAW-Appficwt to eompbts aY Items In sections.1, ll, 04 1V,and IX.
L _ AT aoCATlow Co �..5 u s 5 7
ow
aT
LOCATION
OF. BETWEEN we a t3 ST AIO A ffc • CT.
BUILDING
,CAM STF M �'STRM
Lor
SUBOMSION LOT_BLOCK Siff
II. TYPE AND COST OF BUILDING-AM applicants complete Parts A -D
A. TYPE OF I OVEMOff D. PROPOSED USE•FOR"DEMOLITION"USE MOST RECENT USE
1 IrLnd'ww/swd1q RwlWntltl NeMWrtW
2 ❑ Addapn rd maiden*.enW w"w r a naw 12 ❑ one 18 ❑ Annaanwa,rauaedn-rAt
houwg undo added d anl.a Pad O.131 13 Two 19 D C-wniL pdur M bw A
w3 C3 Aftw r5 2abowl dumb/�-EnM mrmbw 20 ❑ 1nduAVr r
21 ❑ POW BRap
E3RepAr rep4aenra 11 ❑ TnutMwa MIM.nqW,d dwnrAarY• 22 ❑ Sww'm Won.rear ompa
S ❑ wrwirnplan+ntl'Mnlrraad.nAAtwawnwnar E,erww+0aiaraw -
23 ❑ tloapibl treUbdlOrMt
of unrn n&Atb p n Pwt 0. 13) iS ❑ GwapA 2/ ❑ Offim Nan&ptoteAr.wl i
8 ❑ Mahrq lrabotorrl _ 16 a Cwpwt 25 ❑ Prlac Upy
7 ❑ Fwndgw o y - 17 � � 20 ❑ Sdowk M an.abw adn b"
B.OWNER 28 27 Q Tow
B p-1w0 tr4NKksL ewponuwL na ip 29 OdMI SM*
Mel
9 ❑ Pude rFedwM.Staft w btlt gm wmrant
C.COST Iomaeanwr NwaenwbM-Oaevea b aeW ompa"a ue of bu*WigL a.0.bop anxna"Owd
m a 10 wod WWW"bAldbw at lraapaal atenwaw WhOOL Aarotlwy wind,callow
1Q Cost d.nprownwt s 000, PwaaiM Wwa P.tatp-slaps br epwwwa at1ra.m w dfiw brat"cMw trrMdYrp
M baatrMt owt it use of"Uwv buk"a Hera annlsed.wer plopped uft
To ba agwllad but na ndndad
M Ma adpYa Caw
a Ebcb"
a Ptumba q 40, _
e NWrs.aroondNbnYq
d ONwNtA+aeocaml 5e . LO,OffO
1 t. TOTAL COST OF IMPROVEMENT p 2. Z4QUUC
IIL SELECTED CHARACTERISTICS OF BUILDING -For new buiktings and additions, complete Parts E-L:demolition.
compWo only Parts J 8 M.all others skip to IV
P PRRICPAL TYPE OF FRAME R PWXMTYPE OF NEATM RM G. TYPE OF AGE DISPOSAL L TYPE OF MECNAMCAL
30 (3Meary favi beanrR a/33 � 10 Prlle or wmft aammw we s/wa be erlaat edr
32 0 �mw 37 0 EElowtaY 00 11 PrhAla-ePpo WW.alel 16 a No
33 ❑ RwdwtaatnrroAlA 38 ❑ Cel K TYPE OFyYATERSUPPLY WeL1� vyvyanMaaron
31 ❑ omw4lsmw 39 (3OMw-Sow* 42 L��•/Putft or ewa=nowM 48 ❑ yM 47 �o
❑ PrNabbova, b-rN
J.48 NE O M:.'DEMOLITION OF STRUCTURES:
ie umOfl R SIOAa............_...__....._........._.._._.._..__
49. row aware Im of acv area. _ HallApproval from Historical Commission been receiver
a.:noar
fon a wasp m nrnar Z R any structure over fitly(50)Yom? Yes_ NO
50. Tow ww arsa..a 2.__ `� --- ,Dip Safe Number
K NUMBER OF OFF-STREET PARRWri SPACES _ Peg COfltr01:
51
+ HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
u. ou amn..._. Yes No
LRESID®nML BIRDBiGS OM]" ' _. - t jr
53 HMttta
EIBCtria
(�
`
Full_l.— Sewer. 1-,711"q54.
wataa."p DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
�+--�-- BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No_ (If Yes Please ertdose tiocxlmentatiort from Hist Com)
_ . .,.. - . +'r'.: •' � a. - --
Conservation Area? Yes_ No�(If yea.Please endow Ober Pf Conditions)
Has Fre Prevention approved and stamped PIMs or applications? Yes= No_
is property located in the S.R.A.district?M Yes— No
Comply with Zoning? YesL/ No_ (If no.enclose Board of Appal decision)
Is lot grandtattrered?, Yes_= No_�(N yes,submit documentationld no,submit Board of Appal decision)
If new construction,has the proper Routing Slip been enclosed?„ Yew No
Is Architectural Access Board approval required? Yes_ NO M yes,submit documentation) _
Massachusetts State Contractor License# Q 22 3 L46/ Salem License#
" . Home Improvement Contractor# Homeowners Exempt form(if applicable) Yes_ No—
CONSTRUCTION
oCONSTRUCTION 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
FC�. 30 - O G. in wrung tothe Inspector of Bulld)ngs.
V. IDENTIRCATION• To be completed by all applicants
_ Nin /NO"amrma-N~,WI st wr.W90 _ LP Coat TeL Na
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oritiaetlr r/ l/An,r re -.5f �r uaininNa
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ArCIMW or
I hereby cerely go the proposed work is auttiaaed by the owner of record and that 1 have been Summed by the owner to make this application
as his authorized acient ano we rse to conform to all applicable taws of this jurisdiction.
Signature of applicant = Address Application date