128-130 FEDERAL ST - BUILDING PERMIT APP RFCFIVFD
—�� The Comm onweal#'U*A4 a 49YM§
Department of Public Safety
Massachusetts State Br7WW qTRej j10((R2:� '
Building Permit Application for any Building other, an a One-or wo-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
1 SECTION 1:LOCATION(Please indicate Block#and Lot# for locations for which a street address is not available)
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No.and Street City/Town Zip Code Name of Building(ifapplicable)
SECTION 2:PROPOSED WORK
Edition ofMA State Code used_� IfNew Construction check here ❑ or check all 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 ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No dY
Is an Independent Structural Engineering Peer Review required? Yes ❑ No dY
Brief Description of Proposed Work: o
SECTION 3:COMPLETE THIS 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 ❑ A-4❑ A-5 ❑ I B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 14❑ M: Mercantile ❑ R: Residential R-l❑ R-2 R-3 ❑ R4 ❑
S: Storage S-I ❑ S-2 ❑ U: Utility ❑ Special Use ❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) /
IA ❑ IB ❑ IIA ❑ I1B ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public T, - Check if outside Flood Zone e Indicate municipal A trench will not be Licensed Disposal Site ❑
Private ❑ or indentify Zone: or on site system ❑ required trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable ❑ Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No ❑ I 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:
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t , SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner ,7 ,�/
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Brad AJamy 6 0- �Ya j 34v blookilearAq. ca
Title a Telephone No.(business) Telephone No. (cell) e-mail addre s
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to as on the property owner's behalf,in all matters relative to work authorized by this building permit application.
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❑ 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
Company Name
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Name of Person Responsible for Con ction License No. and Type i Applicable
Street Address City/Town State Zip
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Telephone No.(business) Telephone No.(cell) a-m 1-Jdr
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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
Item Estimated Costs:(Labor ,^
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (H VAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ Oyu (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,Thereby attest under the pains and penalties ofperjury that all ofthe information contained in this
application is true and accurate to the best of my knowledge and understanding.
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Please print and sign name / Tire Telephone No. Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: "' c) /
Name Date
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Salem Historical Commission
120 WASHINGTON STREET. SALEM, MASSACHUSETTS 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
Li Demolition 0 Painting
❑ Signage jjiir 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: 128-130 Federal 4treeL
Name of Record Owner: McIntire Real Estate, LLC
Description of Work Proposed:
Repaint exterior with existing colors.
Repair- existing shutters, as needed.
Repair/replace rotted,fascia and soffit„ as needed
There will he no changes to the design, colon, material. or outward appearance of Me building
Dated: November 4 2015 SALEM HISTORICAL COMMISSION
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By.
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.