5 & 7 COUSINS ST - BUILDING PERMIT APP No• &oj 631;l .d City of Salem ward
••,. x 99V
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE-ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT•Apy&M"to con plate au itenp in sections:1 ly lit IV,and IX. �p�q
L AT 44CATWNI / dc+s'�'i.v-5 C>T gSIWCT
LOCATION
OF eETwEEN b,a g/3 �T' AM �pl/� G7-
BUILDING rc"des amlWn Ic"dsa si"t;n
LOT
SUBDIVISION LOT_BLOCK SOM
U. TYPE AND COST OF BUILDING -All appkents complete Parts A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION"USE MOST RECENT USE
1 MIaM auddrq RsslOsnMs1 No"AMtlM1Y1
2 ❑ AddiVMlpnaldM"W.MMnumb o1l 1213 om WWY 18 xvw "Mr.1aCIaMbIW
hCuaeg units added.d aM.n Pat 0.131- 13 �W mme EnW numbw 1913 CMsx e"ar 1eHTCla
3 Q Atlwalwn r/ 2 aawvel of uks T tti O 20 ❑ In&nvia
4 Q Raper MONK011" i4 ❑ TMrd*d nete4 maq W donnbry• 210 Pukh 91sa9s
S Q vAsrag Itl 7lsedrlsp antes amwr Eeprmmbia sites 2213 Sslvan stases.upar 9Maw
23 Q '-, P— :W4lekial
a uma w bwdag m Pan 0. 13) is ❑ G~ 24 ❑ Oeps,Wvd4 a>•CaaaasW
S ❑ Mo.VjmKKxWnl 19 Cl CMomt 25 p Pw [:Idly
7 p Fowamm may 17 p OIl1. samov - m a Sea"libwl7•, e*cvftW
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9 C3 PuOaw IFeft .StM or Nina porMmma
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nrtdl, wm Mu1My -at Meapaa4 @MffWWY smwa.secnrsIWV Sd=d pMM9e.
10. Cop of.nmovemwn s (�Q p o o, selneL Wlkng goaga ICr dspM>rlwr soon,adM dflka Maadit alb s1p"sg
p nMM W OWL d uaa Of 01NWV b uk*V a bnw9 enrlga4 a Wgxud 11sa r
7o a aarw.d ea net named
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11. TOTAL COST OF IMPROVEMENT sZ z�,00p,
III. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Pares E-L:dwndd on,
complete only Parts J&M.aN others skio to N
E. PRINCIPAL TYPE OF FRAME F. PRNCiAL OF HEATVIi FUEL G. TYPE OF AGE DISPOSAL L TYPE OF MECNAMCAL
3013 MMefrylmEsamme 33 � 40 1AM n wwft cix win"TYPEOF Cwwatl9sww�eaa�yMasl at
32 Q ShMM Ma 37 Q EiaMWV 41 ❑ a'Israls lsepee Wik afe.l urn/yas 4513 No
33 ❑ Reidw"edtwlosls 380 Cop H. 1�91TERtIIPPLY waL"h-rManwrsr
3413 ,O�1tl1w•SPswYr 39 Odw-Soso* 42 Irf�l,'lrvose_ aWhals mnOMM 44 C3 YM 47
/itb�w lam 43 0 P1Maes twill awMrs
i
J.DIMENSIONS M:.?DEMOLITION OF STRUCTURES:
+e r+mmn w smnaa..._..._...._._ ._...._-........._._._.. ,...
la. Tam sCuala I"of door am. Has Approval from Historical Commission been received
a:r0ara OfEaa Cn arena `.
for anystructure Over fifty(50)Yam? Yes— No
so. Tam ww am as a.._ -- *Safe Number
K.NUMBER OF oFFSTREEr PAmuNG SPACES Post .
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. OutOoa,s Yes NO
_.
L RE8®B11ML BI✓;mm ON17 - - .� s �t�°s gz/:/�� + �'. • .•
FW_ _. WAOI47
�anaeea. PMuai Z B-DOCUMA PERMIT CAN BE FOR THE ABED MUST BE ATTACHED
N. COMPLETE THE FOLLOWING:
Historic District? Yes— No L of yea please enclose doaunentation from Hist. Con)
Conservation Areas Yes— Nc__�i_--"(H yes pose enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yet v No _
Is property located in the S.R.A.district? Yes_- No l *bk" .r
Comply with Zoning? Yesv.-No— (If no.enclose Board of Appeal decision)
Is lot grandfaBiered? Yea'_ No_L�_'(it yes,submit documentationfd no,submit Board of Appal decision)
If new o'onatruction,has the proper Routing Slip been enclosed?_ Yes! NO_
IsArchitectural Access Board approval required? Yes_ No�(if yes,submit documentation)
Massachusetts State Contractor License# 3Yy Salem License#
Home Improvement Contractor# Hom"ners Exempt form(if applicable) Yes_ 'No_
CONSTRUCTION.TO BE COMMENCED WITHIN SIX(B)MONTHS OF ISSUANCE OF BUILDING PERMIT-
COMPLETED an extension is necessary,please submit
CONSTRUCTION IS TO BE COMPTED BY:
6 p ®lo- in writing to ffre Inspector of Buildings.
V. IDENTIFICATION - To be completed by all applicants
r4" MEiq ao ma•MenriN,aoeat Car,aw am ZIP Code Tel No
Owra . (10.Se ..cc..li"'V S /yjh7 /5 e,_4 lzv, 01?66 q 20--766
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I hereby cenity that the proposed work is authoraed by the owner of record and Blot I have been Sa armed by the owner to make this appiixson
as his authonzea aoent na we agree to conform to all applicable taws of this iunsdiction.
i Signature of applicant Application date
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CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CERTIFICATE OF CCUPANCY / J
LOCATION: GD Cod yut r '� DATE /0!3 /0
APPLICANT: Ct 1, e 12+tJ1 titi L L C
ASSESSORS
FRANK KULIK ATE: U 1
(93 Washington Street)
CITY CLERK L � ��/!fG CHERYL LAPOINTE DATE:
(93 Washington Street)
PUBLICE SERVICES
BRUCE THIBODEA DATE:
(120 Washington Street)4 Floor
WATER /
DOTTIE THIBODEAU DATE: Id
(120 Washington Street)4"Floo
CROSS CONNECT SUPERVISOR
BRIAN THIBODEAU —DATE: _/D
5 Jefferson Avenue)
PLANNING
�/ ' Gi�*/+i* DATE:
(120 Washington Street)3`d Floor
CONSERVATION COMMISSIO
FRANK TAORMINA �� DATE: S
(120 Washington Street)3rd Floor
ELECTRICALsyJ
JOHNGIARDI DATE:
(48 Lafayette Street)
FIRE PREVENTION ,/
ERIN GRIFFIN D 1=,.. �lp�._.r�--Q..-�_. DATE:Z D, 4
(29 Fort Avenue)
HEALTH
JOANNESCOTT C i DATE: /0 -4, `D
(120 Washington Stree Floor
BUILDING
THOMAS ST.PIERRE DATE:
(120 Washington Street) 3 o
l
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use GroW
Permit issued 19— Fire Grading
Building Lin lcadq
Permit Fee $
Ocmpawy lead
Certificate of Occupancy $
Approved by.
Drain Tile 3
Plan Review Fee $
TITLE
NOTES AND Data•(For department use)
z
PERMIT TO BE MAILED TO: i
DATE MAILED:
I
Construction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SWE OR PLOT PLAN -For Applicant Use
O "