19 ORNE SQ - BUILDING INSPECTION The Commomvealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 730 CMR SdMart
�Jd 1 g � Revise)Mnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Lhvelling
This Section For Official Use Only.!'
Building Permit Number: Date pplied', t* '
1 1 i 51 ..
Building Official(Print Name) . -Signature Date,
SECTION L S[TE [NFORt�G�Ti3O.
r
1.1 ro erty Address: L2 Assessors 1 & Parcel Numbers
accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: L4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.01 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Pub[ Private❑ — Municipal On site disposal system ❑
Check if yes❑
SECTION 2:, PROP.ERTY'ON,NERSHIPL '
2.1 wnertof cord:
Ste. 201
Name(Print) City,State,ZIP �� yr} ( A
A7 ) ,/G��'eoi.%1� ) / / 7 !75 ! �51:'( 6.�f__AlOr/N.5UN,
No, a�d Street ' Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR.W'(check all that apply)
New Construction ❑ Existing Building❑ Ownet-Occupied ❑ Repairs(S.5< Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Descr'ption of Per osed 1Vorka: i�
n rid Ite wJ tJ i"I A. A'/" c
SECTION 4: ESTENLkTED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,.
Labor and Materials
1. Building ; /�� 0q--
2. Building Permit Fee: 8 indicate how fee is determined:
Electrical j /JC� 7 Standard.Citylrown Application Fee"rotal Project Cost(Item6)x multiplier x3. Plumbing S . Other Feel:L M:chanical (IIV,%C) S ist: (�i. ,Mechanical (Fin. 0tal All Fces:.S_hick No. Clieck�Aaount: _ Cash Amount:
_
b I'utal Project Cosh S �� 9—+n Paid in Full Cl Outstanding, Il 1hncc Otw
SECTION 5: CONS"rRUCI•ION SERVICES
5.1 Construction Supervisor License(CSL) CS
��53 /q
License Number E.epirl(atiur Date
, nine of CCSL I lolderr • / List CSL Type(see below) d
d, J .0Q —y �V Q— Description
No. and Street
e at,,
(Buildings u to 35,000 cu. R.
! 3 U Restricted 1&2 Family Dwelling
City/Town, State, ZIP M %Aasonr
RC Roofing Covering
WS Window and Sidin
j SF Solid Fuel Bunting Appliances
I Insulation
1'cle hone Email address D Demolition
5.2 Registered Home Ire rovemfent Contractor(HIC)
Ad G.CS MC Registration Number .epiration Date
I I1C bm ny it ur III ' Rc istrant Name r
No. and Stre t Email address
)4 ., ems�� ,
Ci /Town,State, ZIP rele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(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 ........., No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES
/FOR B`UILDI(N�G PERMIT
[, as Owner of the subject property,hereby authorize /S/LO`'c
to act on my behalf, in all matters relative to work authorized by this building permit application.
Gh-Yl
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
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 best of my knowledge and understanding.
Print Owner's or Authorized Agent's Nance(Electronic Signature) ue
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under\LG.L. c. 142A. Other important information on the I1IC Program can be found at
w ww m:us.eov,'oca Information on the Construction Supervisor License can be found at www.ntass.•nt�'dL
[Niunber
When substantial work is planned,provide the information below;
otal floor area(sy. R.) (including garage, finished basement/attics,decks or porch)
n);; living area (sy. 1i.1 -- Ifabitable room count
of tireplaccs _-----_— Number of bedro„ms ----_-untbcrut'bathnonts Nunbdrot'h;dt'batlu --------- --
--- — — —
Lope ofheating ;ystent Number of deck,' porches
\pe rfconling ;yacin __—._-- 1'.tlCJOged — Upco
1. "I oval I'r,y�rt Syiruv Pont i C" m.tv he ,nb;titur I for 1 "t it I rujcct Cost"
CITY OF siu Em. --1SSACHl:SE-ITS
l? r BUILDING DEPARTMENT
120 WASHIINGTON STREET 30 FLOOR
TEL (978) 7 3-9595
F.�Y(973) 7-30-98-t6
:GI.\Q)E1LL.EY DRISCOLL
NICAYOR TI4o.%LuST.Pi ua
DIRECTOR OF Punic PROPERTY/BUILDING CO-NalISSIONER
Workers' Cuinpensation insurance kilTd3vit: Builders/Contractorr/ElectrictansiPlumbers
1 llleant Inforinatinn lease Print Le Ibl
c
Va177C 1OueinvvnQry[n�irati/ )lndividunl): 4! / C Gcf d
Address: J r✓ .
City/State/Zip: net N: 2
[30
e ynu an employer?Check the appropriate basis Type of prn)eet(required):
I am a cmpfoyer with 4. ❑ I am a general contractor and t 6, Nnw,construction
alllployees(full ead/arpart-lime).• have hired the sub cantra.gul
Ind
1 am a sole proprietor at purtner. listed on the attached Adult t 7• Remodeling
ship and have no employees These subcontractor have 8. Demolition
working 1'ur sun In any capacity. workan'comp.Insutnnce �, Building addition
(No workers'comp,insurance J• ❑ We are a corporation and its
rcqulted.) Officals have exercised their 10.0 Electrical repairs of additions
1 sun a homcuwaur doing all work right of exemption per MOL 11.❑Plumbing repoin or additions
myself.(No workers'cump. C. 152,1 I(4),and we have no 12.I]Roof rapairs
insuraneereyuired.) t employees.INaworkers'
eump insurance required,) 13•0 Other
,hay uppllcam dYl ch�ska base r I mart also nil out Ihr u<liw l+elow thowtny Iha4 workan'mmprnmiue pulley inlUrmollon Ihrnvuwnart who mhmii this amdavis indlew1re they amdotng all wont and Ihm him"llideaeninct m music submit a new amdoril indhoting suck
!C.muamon Thal rhivit Ihls baa must mtachod m addlaunot shed showing the nano of the mb.aanrnalore and their wuhm'sump policy(nrornunnoa.
fain an employer that is provlJlne IvanFey'romprntadan Guuranay jot my ampluyera Bduw fa the po/fty and fob sir,
drjonnwloe.
Insurance Company.Name:
Policy 4 or SdGint. Lie 4: Expiration Data:
Jub Silt Address: C1ly/StatdZfp:
.\ttaeh a copy')[the Iroricers'eompensatloo pulley declaration pike(showing the policy number and expiration date).
Failure to rucuru coverage as required under Section 25A of MGL c. IJ2 can lead to the imposition of criminal penalties ofs
tine up 10 51,500.00 untVurone-year imprisanmenk as well as civil penalties in the farm of a STOP WORK ORDER and a line
Of up to 52J0.00 a duy againsl Iha violator. Ile advLmJ that a copy of this slalertlent may bn tarwardud to the OflTca of
In veil iguliuns ui 11id DIA fur iasuranca cuvdrago vcrillcaliun.
/du lrtraby crrrljy audrr thr Gu uuJ r It/rs jparJury r/iur rAe GrjunnuNma provlJaJ�^ubu/J1.21rud uad e
arrect
I' tl ,i• / �O O�S�S � C/
i U//iciu!rue mJy. On nuhvrite in r/dr ure,4 to be rwupbrud by city ur town nJ1lrlu[ t
i
City gr Twyn:
-- - Pcrmlr/i.icenae,9
Issuing Aulhurity(circle One):
I. IfuurJ of Ileuhh 2. ❑a'):nq IJcpurhnmU .1.Cilylfnlvn Clerk I. h:Itetrleal Lupcctnr i. Pfuwhlnq Ll tptctar
6:Ulher
CUtlhc/ I'ertn n:
_ - .. ,-
I
CITY OF S.1- zm. Aks&. cH UsETTS
Bl.=LXG DEP.1RT&NT
..\
I?0 Cf/.0 w HLvc-co,t STnasT, 3 FLoo2
TEL (978) 745-9595
FUC(978) 7-10-934.5
:<l�fDE.�Y DItISCOf1.
,`,LWO"t I�to.%cAjt Sr.PtaRns
DIMCTOR OF PCOLIC PROPERTY/BCTLOLYG CONNISSIO,NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance with the sixU1 edition of the State Building Code, 730 CNfR section 111.5
Debris, and the provisions of NMI, c 40, S 54;
Building Permit hi is issued with the condition that the debris resulting rrom
this work shall be disposed ofTinerly licensed waste disposal Facility as defined by�V1GL c
11 I, S 150A.
The debris will be transported by:
(lame uniauter) 7`---=
The debris will be disposed of in
_-- (namcuYfacility)
sgnanue ut permit applicant
CONUIT�
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:
❑ Construction ❑ Moving
❑ Reconstruction ❑x 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 19 Ome Square
Name of Record Owner: Christine Thomson
Description of Work Proposed:
Install new 1 s`floor window for kitchen. The window will be a Brosco 616 solid wood, single pane, true divided
light and will snatch the existing windows in all ways. Location of the window will be as shown in the attached
drawing.
Dated: May 22, 2013 SAL HISTORICAALL,COMMISSION
By
The homeowner has the option not to commence the work (Lin ess 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.