11 WARREN ST - BUILDING INSPECTION oz
(L. The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
I, J One-or Two-Family Dwelling
This Section For Official Use Only
(n Building Permit Number: Date A lied:
Building Official(Print Name) Signature V D tg✓e
SECTION 1:SITE INFORMATION
1.1 P/rope�rty/�ddress: 1.2 Assessors Map& Parcel Numbers a
L 1 a Is this an accepted street?yes—Lno Map Number Parcel Number c)Q rn
r
1.3 Zoning Information: 1.4 Property Dimensions: D rn
rn
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
G
1.5 Building Setbacks(ft) Cl)
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 yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
�gpm sys-,- W 1&5d l.ad-j S4,6" mw- 01 �? r,
Name(Print) nn// I �C,itty,Statue,ZIP
lI L sNC Lh�/1 I -IV- 45 6e 10
No.and Sneet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify:
Briefrne�s�crtption o Proposed Wprl 2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
S�Yr Te) Co cAT S l z
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Z� PZ J r(I` ] License Number Expiration Date
Name of CSL Holder
-� C. K/� List CSL Type(see below)
(. "'�S�/`4G 1-t�)'L' 7?�" I'�"S �'� Z - Type Description
No.a�-treet
U Unrestricted Buildin s u to 35,000 cu.It)
Restricted 1&2 Famil Dwe m
r/itty/rown,S ,ZIP
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
�. L ' I Insulation
Tee hone Email ad e D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/t7gz
HIC aS zoih
Registration Number Ex iration Date
pany Nameo HIC Repi&trant Name
N d Street ar�Ya�ss
Ci /Town,State,ZIP 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... V No...........❑
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 j t c-f V k V e-.-xs �IOCk
to act on my behalf,in all matters
sr1 -1 9relative to work authorized by this building permit application.
11�
WgqLrte�Thy)3 - 61(,S
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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
c me in this ap licat r true and accurate to the best of my knowledge and understanding.
IN
Prin wner's or Authorized Agent's Name(Electronic Signature) Date
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(111Q Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor 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 halfibaths
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"
CITY OF &U.F.M, 1tLkSSACHUSETTS
• BU;ILDl1NG DEPAR'r% NT
\ 130 WASHNGTON STREET, 3'0 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIN
IBERL.EY DRISCOLL
MAYOR T komm ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BU:ILIMNG CO\06QSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
Mg, Tksmpz-
name of facility)
(address of facility)
Qsignature of permit&applica:n
date
�cbriutT'dce
- _ I
CITY OF S�U.E:�I, �L'�SS.ICHLSETTS
• BI:II.DLNG DEPAMIENT
d• 120 WASHiNGTON STREET,3iD FLOOR
" TEL (978) 745-9595
FAX(978) 740-9846
Ki.\fBFRi FY DRISCOLL
I
MAYOR �fonL►s ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BI:11.DING COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(BusineswOrrgaannizzalioNlndiviidual): e e 7 rSG
Address: � adcA 4a fi'A !; 'Qka%l
City/State/Zip: CG���ia Z�Kq_ Z� Phone#: Cjy1 --9b P - Cf6 0 i
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1
ployces(full and/or part-time).* have hired the subcontractors 6. ❑New construction
2NI am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work tight of exemption per MGL 11.❑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' 13.0Other
comp. insurance required.]
•Any applicant that chucks box#1 must alw fill out the section below shwwing their worked comp"Ution policy mimmadoa
t I Inmeownas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a mm,affidavit indicating such
:Conti urs that check this box must attached an additional shad showing the name of the sub-contmcton and their wod as'comp.policy infmrution.
!am an employer that is providing workers'compensation insurance for my employees, Below Is the policy and Jab site
information. .
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do here certUy under tlep pulps t penalties of perjury that the informatlon provided above Is true and correct.
Sit mat 1 Date: S aD�s
Phone 4 IV? � , � l_, (L — -'"I V,� ��
Official use only. Do not write in this area,to be completed by city or town Official
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other _
Contact Person: Phone#:
T
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
❑ Demolition ❑ Painting
❑ Signage ❑ 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: 1 1 Warren Street, 41
Name of Record Owner: Elaine Wintman
Description of Work Proposed:
Repair/replace deckflooring and handrail to replication existing. No changes in color, material, design,
location or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: May 5, 2015 SALEM H C MMISSION
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.
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