366 ESSEX ST - BUILDING JACKET RECEIVED IQ �
h:SPECTIONAI SERViCES
The Commonwealth of 11tassachusetts
De par ent of Publi wMe#N 19 A ID IS
Massachusetts Stite_Buddir g Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Bu Bdirig Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
3 6(:. ESSey- ewt 0 /970
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Ua Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineerin Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: (�C�i4c e %L"l f,.v l'��Gr�t/� Lui '/"h U t'n yi_jze 4 I t9CC✓H !
1,v1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE W USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
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-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ 1 U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check asap licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ 11113 ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: �l Site❑os Licensed Disposal Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hoards to Air Navigation: \i
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ I Yes❑ or No❑ Yes❑ No ❑
SECTIONS: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 Stipulations:
i�t l--I
. . SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Q3vifdr;j;? ;',
i s 11 v v i 5"O
Name(Print) ! r; ;:, i No:and Street City/Town Zip
Property Owner Contact Information:
CCNI
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner 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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
If budding is less than A000 cu.ft.of enclosed space and l or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
U
10.2 General Contractor - - - - -
CO
-�mpany Name
tv Ck
Name of Pefson Responsible for Construction License No. and Type if Applicable _
Street Add ss Ci /Town . State Zi
7�_�3 i 5 5Z (��_�sy '3�'�7 5 172, _ C C Coivl6; --5
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOltKlih.S'(":OMPI NSA'I[ON INSURANCIi A1;W2\Vl'Y'M.G-.I-F.152 C 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 O
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE . .
Item Esthnated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ v' r Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minhnum fee=$ (contact municipality)
5. Mechanical Other $ -0_ - Enclose check payable to
6.Total Cost $ �(y 5 (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 penalties of perjury that all of the information contained in this
application is true and accurate to the b t of my knowle ge and understanding.
�«!l' e �M � � G,'��� Gf7_?95 3fr5 7
Please printall sign name Title Telephone No. Date ote
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: �!
Name Date
oxwr
1
Annr8�
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSE TTS 01970
(978)619-5685 FAX(978) 740-0404
CERTIFICATE _
OF NON APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ✓ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McI ntlre Distric
t
Address of Property: 366 Esser Street
Name of Record Owner: Phyllis M ll
Description of Work Proposed:
Strip and restore ten (10) 6/6 wood window sashes on first floor of building. Vinyl 1/1 windows to be
installed temporarily. Original wood windows are to be reinstalled by May 1, 2016.
Dated: February 23 2016 SALEM HISTORICAL COMMISSION
By: �(, cc.i , La � /
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.
Once completed,please submit a photographs) of the final result (maximum of four-i.e. one photograph of
each affected fapade).
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.
e m
Salem Historical Commission
ONE SALEM GREEN,SALEM,MASSACHUSETTS 01970
(978)745-9595 EXT.311 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 366 Essex Street
Name of Record Owner: Phy liss Mello Realty
Description of Work Proposed:
Replacement of roofing as necessary to replicate existing. Removal of rear deck and replacement in kind to
replicate existing (with the exception of the outer railing which will require alteration and approval under a
Certificate of Appropriateness).
No changes in color, material, design or outward appearance. Non-applicable due to being in kind
maintenance/replacement.
Dated: June 3, 2003 SALEM HIST C OMMISSION
By: i
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.