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132 ESSEX ST - BUILDING PERMIT APP �r 5 ( 2^ 1 The Commonwealth of Massachusetts W Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ('This Section For Official Use Onl ) Building Permit Number: Date Applied: Building Official: SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 13 �. f=35Q= �Jc. ew, f� p Iq� p Q No.and Stre City Town Zip Code Name of Building(if applicabl SECTION 2:PROPOSED WORK Edition of b1A i e used If New Construction check here❑or check;dl that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other 19 Specify: l :a Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ,5t Is an Independent Structural Engineering Peer Rev!'ew required? Yes ❑ No Brief Description of Proposed Work: k 1l e } :r 1�• a t rtce. t. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Checkghertff�a,,iing Builing Inestigation and Evaluation is enclosed(See 780 ChIR 3-4) ❑Existin : Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of include basement levels)&Area Per Floor(sq. ft.) To'I ATiihil Height(ft.) SECTION 5:USE GROUP(Check as applicable) F: Assembly r\-1❑ ;\-2❑ Nightclub ❑ A-3 ❑ A-F❑ r\-5❑ B: Business ❑ E: Educational fl� F. Facto F-1 ❑ F2❑ H: High Hazard H-I❑ H-2❑ H-3 ❑ H-d❑ FIS❑ 1: Institutional 1-I ❑ 1-2❑ 1-3❑ [ 4❑ Nf: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S1 ❑ S2❑ U: Utility❑ Special Use❑and please describe below: - - Special Use: N SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ - _ 1[A ❑ IIB ❑ IIG� ❑ IfID ❑ IV O VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) d �, Debris Removal: Water Supply: Flood Zone Informal..': Sewage Disposal: Trench Permit: Public❑ Check if outside Flood'Zone❑ lilt numicipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: �I \ lilt n c ninpsi n I ny f r <c,.: Not Applicable❑ Is Structure within airport approj area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition Of Code: Use Group(s): _ Type of Construction: Occupant Load per Floor: Dues the building contain an Sprinkler System?: Special Slipidations:_ — SECTION 9: PROPERTY OWNER AuTIIORIZATION Name and Address of Property Owner QL+rt��r'r5s� �"I Ms�L.�t i6t F55�x St . S`g lcr,..pMU Iq >p Name(Print). No.and Street City/"town LIP Property Owner Contact Information: 4 X't 3 i Lf y 97ar - - so© Title + Telephone No. (business) Telephone No. (cell) a-mail address If applicable, the property oyJner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin•is less than 35,000 nn,R.of enclosed s ace and or not under Constmction Control then check here 0 and skip Section 10.1 t0.1 Registered Professional Res onsible for Construction Control Name(Registrant) Telephone No. e-trail address Registration Number Street Address City/Town State Zip Discipline Expiration Dale 10.2 General Contractor AV^ S = J< �VTow< Co. Tyr: Company Name 5+} -j e'M L— . - y � C -D Name of Person Responsible fo Construction License No. and Type if Applicable 3`)3 Ee,6e)e S" se"Icx , Mid 6010 Street Address City/Town State Zip gy 715�f � _ rcFx ��w�c `te rrFt��k Telephone No. business Tcic,hone No. cull o-mail address SECTION 11:%V'i 1ltNl, ,ORIPG.\�5;\I ION INSIJItA;\CIl:V fl' 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 k No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ 1. Building S Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=S 3. Plumbing 5 �I. Mechanical (HVAC) $ Note: Miniuuuu fee=S (contnU nw ipalit ) 3. eechenial Other S Enclose check payable to 6.Total Cost S OS ©OO. Un (contact municipality)and write check number ue SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Ily entering my name below, I hereby attest under the pains and penalties of perjury that all of the information"untamed in this Application is true and accurate to the best of my knowledge and understanding. S-. illi- .>I-0Iy rZ1 Ii Phrase print,tad sign name Title Telephone No. Date �3 �� t: ys� x sr smlcl , M�r 01910 Street Address .yf�� City/Town State Zip FMunicipal Inspector to fill out this section upon application approval: Name Dale CoNDIT Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 619-5685 FAX (978)740-0404 - CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction 0 Alteration ❑ Demolition ❑ Painting ❑ Signage , ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the.requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Washington Square Address of Property- I I Wa.shingtl�quar . W st/I 32 Fss e Street Name of Record Owner: Peabody.Essex Museum Description of Work Proposed: Replacement of existing asphalt roll and shingle roofs with new black slate and flat seamed soldered copper on the historic John Daland Tacker House and Plummer Hall buildings of the Phillips Library, as detailed in the plans dated 3125113. Work also includes in-kind repairs to the existing wood and metal cornices, and copper gutters. Dated: November 25. 2013 SALEM HISTORICAL COMMISSION By:� ECCLi�!%iC The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work.