5 MONROE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
�•!y J Massachusetts State Building Code, 780 CMR, T"edition OF SALF.M
"'wwwyy// Revised Junnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumi1v Dwelling
This Section For Official Use Only
Building Permit Number: �/ Date Applied:
Signature: ✓ / 5-71Wjo
Building Commissioner/Inspo or of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
r,nNc» S+
1.1 a Is this an accepted street?yes JLno Map Number Parcel Number
1.3 Zo ly Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 inert of Re ord: _
�I Sf<t L3
Nam (Print) Address for Service:
i ure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s)A Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description o Proposed Work: -44 O\J,-e— � t•e i n e
t t e f lace n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 20 68� I• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAQ S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
6. Total Project Cost: S Check No. Check Amount: Cash Amount:
ZO �� D 0 Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
11
1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I Io1Jer List CSL Type(see below)
1-3 PC Description
Address u Unrestricted(up to 33.000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting Coverin
relephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
j D Residential Demolition
5.2 Reg stered Home Improvement Contractor(HIC)
111c Company Nume or HIC Registrant Name Registration Number
Address - Expiration Date
Signature 'rdephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 2SC(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes.......... O No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 71b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
tha a statements and information on the foregoing application are true and accurate,to the best of my knowledge and
ehalf.
dv✓tU✓ts�il
4=nir
z v
caner o Rol Ag nt Date
the aims and penalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Mo.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
�A CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
' I'.IG Ml f l "Klti l'l l
\I J„a I!0 � ��I11.\bJV�I'akri ��•111\I, \L\,i\I I11 J 1,..1'/'.
I'rl:4711.74.143'5 •I:.%x:779•743-'Is46
Construction Debris Disposal Affidavit
(required or all demolition miJ renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris.and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
I llama tit'haultr)
The debris will be disposed of in
(II:IIrK uI 21:1 1ty�
(:1111t/a7�llrlK ltllY/ ...
vynature 1 I tit applicant
ltala
CITY OF S.UI &Nfq NWSACHL:SETTS
SLRDLYG DEP.%RT11ENT
120 W.%sHINGTON STuzr. Y FLOOR
TEL (978) 745.9595
' F.�2c(97� 710.96ii
Kl\®ER"y DRISCOLL "INCAUST.PMRAA
AY01 C)IRWMIL OF PLSLIC PROPERTV/!tl'QDLVG CO-%L%nss1O\Ei
Workers' Compensation Insurance Aflldsvit: guilders/ContractoralElectrlclanslPlumbers
a 1 llean Infarr"all0el
\ l ^
V21119 ItluewrwnaOrtawrwrariewvltwhr duall: v VV
1
Address Sk `
City/Statdzlp
ere you as employs!Cbesk the appropriate boat Type of prRiect(requlredk
1.❑ I am a unploye with 4. ❑ 1 am a Simeral contractor ad I d, ❑New construction
clnployee(Adl and/or part-tims).a have hired the subeemtractorr@
2.O 1 am a sob propries ter partner, listed an the auachad shed I 1. Remodeling
.hip and have no employee Than sub•comra, have a. C3 Demolition
waiting ror me in any capacity. workers'tomµ insurance. 9. C3 Building addition
INo workers'tomµ insurance S. ❑ We we a corperstlw and in 10.❑Floctrical ropaua or addition@
requited.) ofllems haw wasteland their
IT,IT,c I am a homeowner doing ad work right of exemption per MOL 11.Q Plumbing repairs at addltioes
myself.[Nis workea'comp. c- 132•f 1(41 and we ham no I Roof rep@ira
insurance required.) ► employees INe warims' I S LJ Othw
Cornµ insurance mop ird)
-ANY»p►aan ehe darts Too 01 rosier ter.na pan she Mhft telew . I ebeir weAw'eawetwtoeao sulky iw@weWlaa
't hwwrwwnaa whe nebod ilk eradvir iedkmlbf men roe delft ell surd ad tbea blw earridt eeeltaeerta Nm*ewbwt a new MIT Wit Wivaiea era,
T,.ieraaeee the ebeeY ebk M ewM aaeelrt ew alelwwvl eheel.Aewlet@ dwa ntaY e1 the witwrlrMw end tiler,eewbenr'ewnp.pocky iaawwlWea
I ate an ext~that tr pevldlrrs workers'eweywtamefre Inswroworje►tW tsyfWwta Sabw tr rAevNk7 d dM silo
in/ereodon,-
In.urance Company Name:
Policy a or Self-ins.Lie.Ar Expiration Dow.-
job Site Athlrosic City/StawZip
_ attack a copy of the worker,'compemades policy docbratbn pop(sbetrisg the polkly somber mad nplewrloe dab)6
Failure to secun coverage as required under Settles 23A of NGL a 132 can lead to the imposition of criminal penalties of
me up to S 1,300.00 and/or one-year imprisonment,as well as civil penalties in the forma of s STOP WORK ORDER and a flit•
Of up to S230.00 a day agsiml the violator. Ile aehtiwdl the s copy of this statemum maybe forwarded to the O171co of
lnecatlliallune ol'.the MA for insurance cavcraas v%:n&-ltio&
I Ja hereby CIII vn•frr thI ins and pemeldes o/ver/ary their tAw inlMMrloo vnrid rd wbeev iJ Iry and aliened
wan• 2 1
P.'nne a:
Offlcid awe m1126 Oa w a1 wrier ice thir area.n low.utwy/rfd by city of town„flh'ist
City or ruwn: Pcrmit/1.leenstl__,
(.ruing Amhunly (circle une):
I. Iluard ui Ileallb 2. Rudding Ueparimenr 1. Cilytfown Clerk t. Electrical lnsp rcior S. Plumbing inspector
6. 1)ther
L"nlacl Person: _ _ ... pharrt t:
c�
• q
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSA HUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 40-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has detiLined that the proposed:
❑ Construction ❑ Moving
Reconstruction �a Alteration
❑ Demolition ❑ Painting
❑ : Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exernptions 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: 5 Monroe Street
Narne of Record Owner: lohn,Hermanski Barbara Taylor.
bescripti tn'of +"trrk Proposed
Rei nave the state coo#snrggles, reL7laa e wamden roof stieathirig and'r'eia the state rocrfjepi'ac!ng any' roken slates as
needed R ptace existing oa ;cuer tt e Eogf'hips with capper;
I
1 �? I •II i i �1
it
-
i.�
L3ated: onl I3, �C110 SALFl�t I�I6T CIt ShEISSTON ;
I
i
The l orneoerner has: the optirra.not to commence the woik (utiless'`it related to resniv ng an outstanding
uio;fit dn) A31 word omrnu ed mrrs4 hie' cnrpk ted wrttrm ane v an &cSrn thrs date-untess otherwise-indicated'. ,
-
TI tI5,1% td07 A BL7II D1
N G- E R NffTl, P,lease:.be<strt'e to tzt tre CEte apprtiprtat�permrts.Bon the lrrspector of
vtldrngs (or any other necessary Perm : or apPtr-ns als j tlstrtri to cainrneiteuta worlf t
ee of ti i�i t^ F si i I
i - g
I � a i .o-e.. _ ..,c. ... _d T t.�, -.I ,... U 1 .�a...,i. 4�r „e 9•Lt�u._.tA'-,e�.a,�L ,$...L..�..C:... ..� .,x:..:&,. a* .. -