116-118 FEDERAL ST - BUILDING INSPECTION ' f V✓I The Commonwealth of Massachusetts
(V 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 Only) -
Building Permit Number: Date Applied: Building Official
SECTION 1:LOCA'TION(Please i die to Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(;two
able)
SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in tows below
Existinu.a•alding❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ I Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied.vs part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descri ion of oposed 4 crk:
V
SECTION 3:COMPLETE TFI[S SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN 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 ❑ A4❑ A-5❑ B: Business ❑- E: Educational Cl
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional [-I ❑ 1-2❑ 1-3❑ 14❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ 1 HA ❑ 1[6 ❑ IfIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CAM 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal: Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ 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{\1 h 1�ninnvm s�>n I vice 1 r xtsr,
Not Applicable❑ Is Structure within airport approach 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:
Does the building contain an Sprinkler System? Special Stipulations:
14
SECTION 9: PROPERTY OWNFR AuTifORIZATION
Nan! and Address yfj'rope rty Owner
Name(Print)
No.and 't et City/Town, Zip
Property Owner Contact Information:
'title Telephone No.(business) Telephone No. (cell) ;-e-mail address
a
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 building permit a2plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 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
10.2 General Contractor
CoUipLiny Name -Tc
o. l
Name of Person �sponsible forstrudion A A ` Lice No. and Type if Applicable e+
(&r , � fi
Street r\ddress " r� �.Ci[y/Town tatg Zip
G e1 c7O` t C� �S gv G715 j) J�e��
Telephone No. business Telephone No. cell
e-mait address
SECTION 11:Wi:)RI:b'.Pti'CC)niPENS�'I'IC?tv INSUR:��\C6::\1 I'ii.myi'I 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Rem
and Materials) Total Construction Cos[(From Item 6)=S
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
Y)
d. Mechanical (HVAC) $
5. Mechanical Other `� Enclose check payable to
6."total Cost S v (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, y attest wafer the pains and penalties of perjury that all of the information contained in this
A lication isptr�ue and accumtc o th best of my knowledge and understating. 7 fy
Please rinry_itnd sign nan,e� title `,Tel Rho,No. Date
Street Address City/Town at`7� lp
117
bblr�/ �
Municipal Inspector to fill out this section upon application approval: Date
Name',
07/08/2013 09:00 FAX 978 539 0088 ZONE LABS INC. 0 001/001
e m
Salem Historical Commission
120 wASHINGTON STREET,SALEM,MASSACHUSETTS 01970
(978)619.5685 FAX(978(740-04%
CERTIFICATE OF NON-APPLICABIIITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
Cl Lstruction 0 Moving
❑ .#3'Instruction ❑ Alteration
Demolition ❑ Pig
iignage ❑ 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.
st .
Distriek McIntire• ..
Address of Property:
Name of Record Owner: Leach Naphok Conde Association
Desch'otpr,, of Work Proposed:
- with new hardware (not visible from the public way)
Rt3ee gate hardware
-*arp center back door (in-kind)
-Repi,_:•x.front fir door(in-kind)
-Replace roof on right side with rubber roof and repair crown molding (roof is not visible from the public way)
-Replace roof on the left sidem'ith rubber roof(roof is not visible from the public way)
-Repair front stoop (in-kind)
-Replace the water table trim on the left by the electrical service entrance (in-kind)
All new wood work will be painted to match the existing.
Dated: July 3. 2013 SALEM WSTORICAL COMMISSION
By. ..
Teo.g6r.j1w jmd has the option aot to commence the work(unless it relates to resolving an outstanding
Vkitatir.:q. 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.