61 SUMMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
ts� Revised✓onuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 1008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb r:/f,,-. Date Applied: /�
i(\ \ Signature: v�"� 7 J
vr` Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 roperty Address: 1.2 Assessors Map& Parcel Numbers
-
I.[a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(it)
1.5 Building Setbacks(D)
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 ifyes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 //Owntler'of ltes aord:
.V / vo.._
No Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Descripti n of roposed Work': e 1r1� 0
OP
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6.Total Project Cost: S 9--}—j0 Check No. Check Amount: Cash Amount:_
❑Paid in Full ❑Outstanding Balance Due:
C6 yv+rccm r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /tS �'03�5--X ( "'/—/o
/.]., y, �: �y� Lictnse Number Expiration Date
Name of -I IulJtr list CSL"rvpe(see below) (Z
' T pe Description
Address u Unrestricted(up to 35,000 Cu.Ft.
2'e Ail }/T/ R Restricted I&2 Family Dwelling
Sign lure n M Masonry Only
♦/fT%� RC Residential Roul'ing Covering
rcleph ne WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2,�2 d Home lm rovement Contractor(HIC) A ��3
II&/?` ��� Registration Number
o Par�yC or HIC R gisirant Namy� D� I /
Add y —!/
,4 G7,1 -L-rr�, Expiration Date
Signatu Telephone
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 BUILDING PERMIT
1, Pon Cam/bU as Owner of the subject property hereby
authorize A c F _( /� �h �O to act on my behalf,in all matters
relative work It feed by this building permit application.
SiLtIature of Os ate l ��
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 Mol 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 basement/attics,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
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission
Ordinance, application is hereby made for issuance of a Certificate of Non-Applicability for:
❑ Construction ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
as described below.
District: Original Building Construction Date, if known:
Address of Property:
Name of Record Owner(s):
Description of Work Proposed:
Signature of Owner: Tel. #:
Mailing address: City: State:_Zip:
r
PROCEDURES FOR FILING APPLICATIONS
A. Ile prepared to apply for approvals well in advance of commencing any exterior work. Before making any changes to the exterior of a property
in an historic district,the owner should call or visit the Commission representative at the Department of Planning&Community Development to
discuss proposed alterations and to determine the category of the application(Appropriateness, Non-Applicability or Hardship).
B. The Commission normally meets on the first and third Wednesdays of each month and notices are posted at City 1-fall. The meetings are held at
120 Washington Street,3rd floor,and begin at 7:30 p.m. All meetings are open to the public and any person is entitled to appear and be heard
on any matter before the Commission before it reaches a decision.
C. An application for a Certificate of Appropriateness or Hardship must be received by 3:00 p.m.on the Monday 16 days before the meeting in
order to make the agenda. An application for a Certificate of Non-Applicability may normally be added to the agenda up to the day of the
meeting. In some cases,a Certificate of Non-Applicability may be issued by the Clerk,without review by the full Commission,after notifying
Commission members and allowing 24 hours for any objection. There is no fee for any applications.
1). All applications for Certificates of Appropriateness or Hardship require a public hearing. Notice of the hearing must be posted with the City
Clerk 14 days before the hearing and abutters must be notified in writing. Commission statl'will handle these procedures. A public hearing is
not required for a Certificate of Non-Applicability.
I . Applications must be submitted by the owner of the property. A contractor for the owner,at the owner's request,may submit an application on
the owner's behalf. In case of a tenant,a waiver of the owner's appearance maybe granted at the discretion of the Commission if it is requested
by the owner.
P. All applications must include three to four 35mm photographs of existing conditions. No certificates can be issued prior to receipt of
photographs.
G. An application will not be considered complete unless all work items are thoroughly described on scaled drawings and include specifications
regarding dimensions, materials, and any other information needed for the Commission to visualize the changes in order to make a
determination. Applications for paint colors should include a paint chip or chart. The following items should be included in your drawings as
applicable:
I. Site plan showing location of improvements;
2. Elevation drawings of the specific improvements;
3. Details/profiles(i.e.moldings, fence caps,cornices,vents,etc.);
4. Materials(i.e.wood,brick,etc.);
5. Dimensions(i.e.size of trim);and -
6. Transformers,heat pump and condenser locations,electrical entries and meters,lamp posts,stove pipes.
Ff. At the hearing,the Commission will discuss the application with the applicant or his representative,hear the abutters and take a vote. Owners
having professional consultants such as architects or contractors are urged to have them be present at the hearing. Ifthe application is approved,
a Certificate will be mailed to the mailing address provided on the application and copies will be sent to the City Clerk and Building Inspector.
Please note that the application can be continued until the next meeting if the Commission deems necessary(i.e. for reasons of incomplete
drawings,to perform a site visit,etc.). In any case,the Commission must make a determination within 60 days from the date the application is
received, unless the applicant waives that requirement in writing.
I. A property owner or a contractor cannot receive a building permit unless a Certificate has been issued. Please be sure to obtain appropriate
permits from the Inspector of Buildings(or other necessary permits and approvals)prior to commencing work.
.I. "fhe homeowner may opt not to commence the work approved(unless it relates to resolving an outstanding violation). Work commenced must
be completed within one year from the Certificate date unless otherwise indicated.
K. The City of Salem reserves the right to inspect the project to determine compliance with the conditions set forth in the Certificate issued.
Violations
A person commencing or completing work to the exterior of building in an historic district without the necessary approval ofthe Commission is subject
to fines of up to$500 per day from the date of violation. The Commission is not responsible for an owner's neglect to inquire about necessary City permits
and approvals. All records are public and we will confidentially assist you if you are concerned that someone in your neighborhood is in violation.
Assistance
The Commission's guidelines are available for viewing at the Salem Planning Department and the Salem Public Library. the guidelines provide examples
of what is historically appropriate(or inappropriate) for Salem's neighborhoods including trim, siding, doors, fences, gutters, masonry, paint colors,
parking solutions, porches, rooting, satellite dishes, secondary egress, skylights, utilities. windows, etc. "these guidelines help you understand what
changes are likely or unlikely to be approved. "fhe Commission supports your efforts to improve your property and can guide you on historical
appropriateness, further information,in the form of books,articles and pamphlets,City-wide architectural inventories.and photographs.are available at
the I listorical Commission's office at 120 Washington Street. Por more information. contact the Clerk of the Commission, Jane Gov, at the Salem
Planning Department. 120 Washington Street,Salem, MA 01970,978 745-9595, Est. 311. Rev.I(X)4
t
CITY OF SsUY-` s NWSACHUSETTS
& aMLNG DEPARTMENT
1'_0 W.uHLNGTON STREET. )m Ftooit
TEL (978) 745.9595
FAx(978) 740-98"
KI-(BERIEY DRiSCOLL
�(AYO� T20h1As ST.Pimus
DIREcroa OF Pl.eLIC PROPERTY/et:ILDLNG CONMU SIONER
Workers' Compensation Insurance Affidavit: guilders/ContractoNElectricirnVPlumben
aunllcant Infnrmatiors ( Please Print Let2iblY
Marne(ausinr Crpniratiomindividual): 4ZE laithar"yi t 0
Address: / 9,4 A C_r
City/StatdZip: v Ala-/J7 Phone M. 7rf —CJ�G
F
you an emplaysr'Cheek the appropriate boa: Type of project(required):
1 am a employer with 4. ❑ I am a general contractor and 1 am to p e have hired the subcanractors6. ❑New canstrtaction
p yew(fWl and/or art-time),I am a sale proprietor or partner- listed on the attached shcet: 7. ❑Remodeling
:hip and have no employee Thera subcontractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance 9. ❑Building addition
INo workers'comp insurance S. ❑ We are a corporation and is 10.0 Electrical repairs or addition@
rLelWred.l officers have exercised their
1.❑ I am a homeowner doing all work right of eaanpion per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152.f 1(4).and we have no 12. Roof repsirs
insurance required]t employees.INo works=' I J.�Other
comp insurance required.)
-Any oprlina ttus checks boa e1 muse aim nor wA the mum,below ihowiq node weber'wtntsmswLm purity irrfwmulma
't f.mum minis who submit this aMd.vis indicating ihoy an"a all work ad thus hie chaise ease n.orr submit a maw aMdavil irlioriq OWL
4'.mawsvan dwi rhetk This bon must anwhist as add Immil shod showing dw nwna o(the eb4osai nalr and Ask -aim .ramp.policy information.
/Ras as empleyar that h previdbrg•workers'compraswdan lnarronee for my esplayees Below/s/fie pWICY aedm iUr
informalka
Insurance Company Name:
Policy 4 or Self-ins. Lie.M: Expiration Date:
Job Site Address: City/StatdZip:
,%Crack a copy of the workers'compeasetbn policy declaration pap(showing the policy number and expiration daft).
Failure to secure coverage as required under Section 25A of MOL a 152 can lead to the imposition of criminal penalties of
Rne up to S 1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tie
of up to S250.00 i day against the violator. Ile advised thst a copy of this statement may be rurwarded to the Otfice of
Imcarillwiuns urtho nlA for insurance coverage vcritication.
l do hereby certify Under the pains and penaGiis of perfury that 11m informadon provided above it true and carrreg
� _nunue: tuba: 7 —13-10
Phure A: 7-1-1 -l/
Off a ial use a dy. Do er Of write in this area,to be.unnpleld by airy or laws uf/la•ial
city or fawn: YcrmiN.lccnseM__
1%suing Authunly lcircle one)-
I. Iluird of Ilealth 2. Ruildlnu Depirlmrnt J. Cityirown Clerk 1. Electrical Inspector 5. Plumbing ingpeeoor
6.Other
t..,nlaerenoac _ ._ Phones:
�S CITY OF SALEM
l;
• PUBLIC PROPRERTY i
DEPARTMENT
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Nt \{.\•III.\t,.o14SI'sLCT 0 SA I M. MA».\\I U J I •:I'I'_
I F1:4711•7/j.9595 •1'.\x:9711•740-9946
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR scction 111.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit p . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Iilarm ot'hauler)
The debris will be disposed of in
r nameul�uy)'
plddres�ul'1'ac0uyl
.igna a of permit applicant
date
\I ass auhuseltr Dcpartniuit of public 5 d'Atv..4'
1 Bnard.of,Bwldin„.RUgulitiono:andMandards
r Construction SyRervisor&License €
License:,CS,90352 ,E Ali
i Retncteddo,r04 }M
ANTHONY J,FIORE-
19ATfDFOR -AVE
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