11 DANIELS ST - BUILDING JACKET li�� mr . •. y�,�,�'qr.
�rLISIL
WMAROVED BY 741E
10R AEWR GRANTED "'+t
B •.;;.
_ CITY OF SALEM
No.
Is�L In Lwatun o:
rN t
• FNat0b DWIktd 1bI? YN_N0
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BUILDWG PERMIT APPLICATION FOR:
Permit to:
(Ci(de whW~apply) Roof, Remof, install Siding, Construct.Dw K Shod, Pool,
apa Rsplaco Other
PLEASE FILL OUT LEOIBLY A COMPLETELY TO AVOID DELAYS W PROCII"
TO THE INSPECTOR OF BUILDINGS:
T WW hereby applies for a pwmk to build according to fhe faNwA p
Owners Name -DAAD 2�r`Cy
Address d+ Phone .SO Ia— amtSbx5 4jc- (M) SIN
01*1 !
Arohiteds Name
Address & Phone ( )
Meohenlcs Name
Address & Phone
3 S what is to p.pm d armrg4 Z [D Ti All r'...
LWMW or talwnp4 N a dwmN g for how mmy hm1w4
G Wokdit bI A30
INNS pap
Cey Lbw"• am"LbN N 5£s 3 I
s 1ar I�ro+rat ''
�4 Signature of Applicant
J � SIGNED UNDER THE P�'
OF PERJURY
DESCRIPTION OF WORK TO BE DINE
��3 l.G ILIf�/n FPS �C� �p,� ` . � �`fLl.t.. �Fi.►tftS d /�' ,A;
- u S' - r4 CC_ i2
MAIL PERMIT TO• S� bcu ti+(,�cs � Q
IVY
Ing
Na
APPLICATION FOR
LOCATION
PERMIT GRANTED
5 wo �e
r
INSPECTOR OF BUILDINGS
t
I
at �4.41i1te91fl4fs �E {- 4" PPROVED BY T44E
T B,EING GRANTED
T� to
i,. CITY OF SALEM
_ o"a
No. , . ZOOS{ �+ �+ Date L\ /1v/e,3
iI Ward
\ m Zoning District
Is Property Located In Location of
the Historic District? Yes_No ✓ Building �� �an.GIS s4
Is Property Located In ✓ f�
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) eroof Install Siding, Constru t Deck, Shed, Pgol,
Repair/Replace, then. aA,6,kty (,s+ �r�sj.of
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name
C ref � (�cs5
Address & Phone
C �,mpl2/'G
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( (f 1
What is the purpose of building?. -I-\.J ) B / Cnr P-klJ 4 I o �° s
Material of building? lJoa4. If a dwelling, for how many families?
Will building conform to law? Asbestos?
( S o OB c
Estimated cost _ oo-ad City License# State ucense #
2 S d0 l C b Home Improvement
6 ° Lic. ISigns ure of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE 11
k-&,A ty 5 w hdws t.Is}L d S&c J, ,,6 rw3 a d�
Lah'� Z V-Vvy, Cr o� scrod -Plan 3mA�
A rca r ,ohs °r �Wl&5 av,
MAIL PERMIT TO: y2.nvt•5an ay�
/o PC,; , C, (h
1 f
x
,.. i ,t 4.? .. ::ra< ,.r r
I
. . � ..^.,�� 4 F".. � �. e �0l��#� ....ai. ".1'F r 1,.> •1�x��4�n s i w�'�r . ., F 1 �_. � 6 d,�:3.,T., ,..
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Lafayette to
'I've
C ieJ 91'X744-14';5
7j- 146 n� FaX 9�W-7-15-4646 91-8,74P
FI
RE
D_
PPA�T14F.NT CF_RT_LPICATE OF APPROVAL FOR A BUILDING PERMIT
FT_ T
IN ACCORDANCE WITH THE P?JOVtsIo1,s OF ME WSSACERUSETTS STATE BUILDING wIDE
AND IM SALE14 FIRE CODE, APPLICATION IS HLIMBY M"E FOR THE APPROVAL Or F1
SNS
AND THE ISSUANCE OF A CERTIFICATE OF APPROVAL FOR A BUILDING pE2,,K-T By -qiE
4�
SA.LM FIRE DEP&RTMENT. Ref. Section 113.3 of the Rass. nldgz co4le)
JOB LOCATION:
OWNER. /OCCUPANT:
wd
ELECTRICAL CONTRACTOR: C
FIRE SUPPRESSION CONTRACTOR:
SIGNATURE OF
APPLICANT. PHONE
ADDRESS OF CITY OT
APPLICANT:
TORN:
APPROVAL DATE- 1/0 r,3
Certificate of approval is hereby granted, on approved plans or submittal of
project details, by the SALEM FIRE DEPARTMENT. A-11 plans are approved solely
for identification of type and location of fire protection devices and equipm-ant
All plans are subject to approval of any other authority having J4orisdiction.
Upon completion, the applicant or inataller(s) shall request an inspection and/or
test of th-- lire protection devices and equipment. (ADDITTIONAL REQUIRMNIENTS,
SEE IREVERSE SIDE
NEW CONSTRUCTION.
PROPERTY LOCATION IIA-S NO CW1,7111110E (41TH THE PROVJSIoNS oF
A<J C11.kPTER 148, SECTION 26 CIE, RELATIVE TO THE !NSTA. 1-
TION OF APPROVED LITRE ALARM DEVICES. TRE OWNER OF' -i';!1S PRO-
pEii,ry
1. rS REQUIRED TO OBTAIN COMTLiAACE AS A Cf,?D)T
OBTAINING A BUT111W PEM-11T. _TION OF
10ATION' :Eu (`j fmZ
148, SECTION 26 C,,S,
Cr1 I 11A f r N
4
7, 1.
o' 0'o
o
in Compliance wilth the pro,. ision of Section 113.5 of Choe Xa ; s+ ttuz:v tts
State 9u, icizng Cede, a^rs under guidelines creed upar by the ui . A Bldg.
Inspector and the Salem Fire Chief, the applicant for a building ;;ermit
shall obtain the Certificate of Approval (see reverse side) .and stivipe{
plan approval from the Salem Fire Prevention Bureau.
Said application and approval is required before a building pevzlit ;lay- 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: Flans will not be required for structural work when the
proposed work to be performed under the building permit wig
,not, in the opinion of the Building Inspector, require a
plan to show the nature and character of the work to be
performed,
Notice: Plans are normally required for fire suppression systems,
fire alarm systems, tank installations, and Fire Code
requirements.
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. In these
cases, provisions of article 22, Appendix T, and Tables applicable
shall apply. This section shall not, however, supersede the
provisions outlined in the Salem Fire Prevention Regulations, Chapter
188, MGL, or 527 Code of Massachusetts Regulations. 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 Laws and/or
Codes, but the existing structure may comply with 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.
I
�tI�
CommonWILG.LLlL 01'mmeQcjtwrsi.16
-. JJeperlanaul a/�.�,islia(�ce;d.ufs
6 +
JamesaCamcod �ai•� !//eaaaeM+u�W 021I1
commssow
Workers' Compensation insurance davit
1,
(ao�./ �- Izt t c' or"Ci(+n,AC i1�ipL-r. T�o-IL�
eorw.+a.e� J
. . witha principal place of business at:
. . IGer�aa+a✓air
do hereby•ctnify under the pairs and penolties of per!Mo that
() I am an employer providing workers' compensation coverage for my employees working on
shis job.
policy Insurance Company � Po cY Number
I am a sole proprietor and have no one working for me in any capaaty.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hi . the
contractors listed below who have the following workers' compensation porcles:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Poligq Number
Contractor Insurance Company/Poliq Number
O I am a homeowner performing all the work myself.
I unoencand wt a coot of"wive ern�M be ion+aroed td the once el lmotit+a.ant of the DIA for coeerate eetiRtadw and Mat LAM ro a.eere
co.erart x reovrca under Section 2SA of MGL 15 2 can kid w ton:noonuon of oa+.na oenxnes corsatint o1 a bee of w w41.5=00 aedler ON
ream'�aruo r,ent v,to ar ciei oena11ie1 in the foam of a STOP W ORK OKI)ER and a hoe of S 100.00 a ear gi.ot one.
Sirned this day of
I-ictmttl'Ferm4tte builcing Geparcre+ent
:ten ing Eoare
Seiemmens Office
-,vlth Dcp:�mc^..
doe r0S , -0oF , 77E
PUBLIC PROPERTY DEPARTMENT
• 120 WASNINaTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL. (978)745-9395 EXT.360
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this BuildingPermit shall be of in a Y disposed properly licensed solid-waste
disposal facility,as defined by M(X c III,S 150A.
The debris will be disposed of at: Ni PZjA4 e,C De CAa:Z cZ r l(fir
Location of Facility
Paz d�1�c�utR�slZ�� 4 i►, .,�1�C ; o
Signature of Permitit Applicant DaA
FULLY complete the following infomlation
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any '
y-�6
Address,City&State
The above statute regains that debris from the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIll,S 150A, and the building permits or licenses are to
indicate the location of the facility.
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SuWed to eDpiroval by any
CITY
of 03Mti-L�j, P,',A2;1
BY
PLANS ARE AP-RAYED SOLELY F'G'I
TYPE AND 1 --IC", 07
ALL'IRt E,
FINALT STI MD INSPEGM-li,iCF COM
ANCE WITH THE FIRE