188 FEDERAL ST - BUILDING INSPECTION 00 Z
RECEIVED
rt"Pj _ I y _ Zg 5 INSPECTIONAL SERVICES
The Commonwealth of M a tt
Department of Public Safety ID: 44
YU Massachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use OnI )
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)
V4 FECAL S - b4EU
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here Igor check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration V 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix t)
Change of Use Cl Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 9 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No GT
Brief Description of Proposed Work: eOUSTRNCf t elo D�GK AA�j
R�11cr�ArlooJ aF K0-c-"C-k) ICd/�`ft �� fr.)cc l.�DtNa rtJb�G4L44
o Lo+<d� del c� f�LYrM
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 Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-I❑ A-2❑ Nightclub ClA-3 ❑ A-I❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-t ❑ H-2❑ H-3 ❑ FI-4❑ H-5 Cl
1: Institutional I-1 ❑ I-2❑ 1-3 Cl 1-4 ClM: Mercantile❑ R: Residential R-I❑ R-2❑ R-3 Cl R4❑
S: Storage S-t ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Perm us-al Site❑
Licensed Disposal Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p s
required❑or trench or specify:
Private❑ or indenli(y Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: FfazarJs to Air Navigation: CIA Ili,I, .i �.�nmmi�tii m 1"',w',
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: (hcupant Load per Floor:
Does the building contain an Sprinkler System?: __ Special Stipulations:
s�vz =► S I ,
. SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address bf Property Owrfer L i
MQ.&MZ. LEx/E6QIA( I WK 1=EDEIRAL sT.
Name(Print) . .e A 'No!Ad Street City/Town Zip
Property Owner Contact Information:
M2 k MPS L SQL C __ 611-175< r6`64_
'ritle Telephone No.(business) Telephone No. (cell) a-mail a ddress
If applicable,the property owner hereby authorizes
3uslno `rj it.- 1fa S "L 41AY�PI� sc_ 2 SW Iext1P-<AVt7 t-tq O1`IO-+
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 ermit a lication.
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 D and ski Section B.t
10.1 Registered Professional Responsible for Construction Control t C. 17 3 O L Z �S `Z-1
5. W11 I_tOct15 60f_33s _ ar�S IkOVI�inc('titshla� C g- �4, 3 9 �(
Name Registrant) Telephone No. e-mail address Registration Number
4% ZAMP4,40C� Zr- SwAr IP��' (''� C1c+0'-� I '? 7 I S
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
SC,ISTIIJ (,J ILL IA1''� 1?N-)
Company Name
Zy_ ( )ILLII-MS
Name of Person Responsible for Construction License No. and Type if Applicable
4a6 f-(LAO?4.12C� S;'. EQkf-�CO-Tr- HA Ola a`4-
Street Address City/Town �" State Zip
$1.gn 252-I _ - �I I S yy!1 (-A/ r C- (--) Ootmoir I
Telephone No. business Telephone No. cell a-mail address
SECTION 11:4VORKIr:RS'COMPFNSAI']ON INSURANC01,AFFIDAVI I' M.C.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=$ 40�CDD 'cic�
I. Building $ 2,01 0C30 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S $, coo appropriate municipal factor)_$
3.Plumbing $ 0-cr7
4. ��lechanicai (HVAC) $ Note:Mininutm fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost 1 $ 40,Ott , c3o I (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
�t,�STItJ W ILL IA1--15 MTz. �6.353. `1f�S 8 t fy
Please rfnt and sign name Title Telephone No. Date
��6 +{tini NPC`) 5r TF t-W aQ
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF Si\LENI, %L\SS.ICHUSETTS
; .
4 BUILDING DEP.\RT\(LNT
� rf
120 WASHINIGTON STREET, 3oa FLOOR
lg ° TEL (978) 745-9595
F."(978) 740-9846
IU\tBER1 EY DRISCOLL
"Asi.YOR TriObL1s ST.PIERRE
DIILECTOR OF PUBLIC PROPERTY/BI:ILDMG COMI]MISSIONER
Wnrkers' Compensation insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Aplilicant Information Please Print Legibly
ihiv
V;unC(Ilusines Organizmiomindividu:d): :TtgSTlty WILLIR VIS CtJt��t/�cfIG1J
Address: 496 t LAF,PoQ4-,) 57. 92
City/State/Zip: 9LJAI 1P6C0TT-r A• 01 q6_4 Phone /i: SOr6 �63
Are you an employer;'Check the appropriate box:
'Type o7rcpairsor
quired):
1.0 1 am a employer with 4. ❑ I am a general contractor and ( -
emplayeea(full and/or part-time)." have hired the subcontractors 6. ❑Nconstruction
( 2.0 1 am a soic proprietor or partner• listed on the attached sheet. t 7. ❑ R
' ship and have no employees These sub-contractors have 8. D
working for me in any capacity. woil(ers'camp. insurance. 9, 0 Bition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Eairs or additions
3.0 I ant a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself. (No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' I3.❑ Other
comp. insurance required.]
'Any applir 1111.1 chccYl but 01 Moto uIw fill out the section below,hawing their wotkm'cumpensaliun policy its;,madon.
' h+manwlwn 11he,ulonit this alndivit indicating thry m doing all work mad then hire uubide contmeton mml auhmil a new an?davil indicating such.
$'•imncwn that chak this bus most mlachal un additional shin showing the mono of the subaentnctun and their workers'comp.policy information.
1 ant un eitipluyer shut is providing workers'cunlpeiisailora ireturattce for my employees. Below A the pocky and Job.rile
iu�rrmatian.
Insurance Company Nmne:
Policy 4 or Self-ins. Lie. d: Expiration Dote:
full Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
E'ailure to secure cuvernge as required under Section 23A of bIOL c. 152 can lead 10 the unposilian of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he form of a STOP WORI(ORDER and a Tine
of up to S250.00 a day against the violator, lie advised that a copy of this stalement may Ix: forwarded to the OI'lice of
iu vest igai ions o(tlie DIA for insurance coverage veri fieatiun. -
i do hereby certify unde the painr and reualties of perjary that the 6tfurrnutlon provided abuve is true and correct.
4ij tirc Data: S 1 4
Phone
[6.
cial use only. Da nor virile in this area, to be completed by city ur town agh-iut
nf'I'uwm: _ Permit/License 4
ing Authority (circle one): ---
Board ul Ilcahh 2. Buildlnt; I)cparluu•nt .I.Cilylfnwn(_'Icrk1. Elcetricsl Inspector S. Plumbing Inspcuor
ther
( oaliict Tenon: Phone;t:
QTY OF SALEM, MASSACHUSEM
y BUILDING DEPARTMENT
\,
a` 120 WASI�-I+I,N. GTONSTREET,3" FLOOR
1C�+Ntruscfl� L. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
KIORM-\ Sinp CA2TIN
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign\ature of applicant
Ss/I �14
Date
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:
10 Construction ❑ Moving
❑ Reconstruction IHI 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: McIntire
Address of Property 188 Federal Street
Name of Record Owner: Kevin and Leslie Levesque
Description of Work Proposed:
1. Remove two (2) casement windows and install one (1) new double-hung wood window with true divided
lights, exterior storm sash, and wood trim,per the application dated 5119114. The color will match the
existing windows.
2. Remove existing stove vent and replace with new metal vent in the location identified in the application
dated 5119114.
3. Construct a back deck,per the application dated 5119114 and the drawings dated 5/8/14. The new door
color will match the existing doors.
Dated: June 12, 2014 SALEM HISTORICAL COMMISSION
By:
The homeowner has the option not to commence the work (unles it relate 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.