17 WARREN ST - BUILDING INSPECTION Si
The Commonwealth of Massachusetts rp 3r)4.ru
Board of Building Regulations and Standards �CITLENNI
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Massachusetts State Building Code, 780 CMR 1 1 etrYeSl:f/a 2AJ
Building Permit Application To Construct, Repair, Renovate Or Demolish a It 3
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
nn Building nnkii l(Print N:tme). Signature - - Date
SECTION 1:SITE INFORNIATIOW
I.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.l a Is this an accepted street?yes_ no Map Number Parcel Number
I— 1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Witter Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION2: PROPERTYOWNERSHIP!i
2.1 Owner'of Record: SAtjt I M 4 Gie76
r�b r
�me(Print) City,State,ZIP
I? WoAkk)si 97Y 8Yys9s�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building 0, Owner-Occupied ❑ I Repairs(s) ® I Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other O Specify:
Brief Descr' tion of Proposed Work"- :To /A15rAL- AIk aJ 3 L42 ASON4t 't- 00 1C 2/a16(1--5dn)t4(l
iAr+1A) P//f(afd P_dao V1,06i e7AJ wcnia/ 41V41—S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Itcm Labor and Materials)
I Building S O / i. Building Permit Fee:3 Indicate how fee is determined:
❑Standard City/Towo Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S n
4.Mechanical (IIVAC) S List: C
5.:\Icchanic1
I (Fire S Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
6. 'rotul Project Cost: S 6 &00, 0 Paid in Full 13 Outstanding Balance Due:
a . r
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstructimrSupervisor License(CSL) It)I O I f }I�l
A) m�V4K)Zlf— License Number_/ Expiration Date
Name of CCSL Holder List CSL Type(see below)
Type Description .
No.mid Street
Unrestricted Buildin s tip to 35,000 cu.ft.)
Amoy /Yk olalo Restricted 1&2F:unil Dwellin
Cityffown,S1 te,ZIP Ai Masonry
AC Roofing Covering
S WindowandSidin
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC) Ibli�� � 1 /�
T�ivu�n era/ (Oit,*A4r-0�5 HIC Registration Number Erpi on Date
HIC Cun)pmy Name or HIC Registrant Name
No.and trees et Email address
b ✓n ale? q7A-53/-Aee
Ci frown Stat IP Tele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L:C. 15Z§ 2$C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
denial of the IsS uance of the building permit.
this affidavit will result in the de g
Signed Affidavit Attached? Yes ..........A. No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.W HENs
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Naine(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
contained in this application is true and accurate to the best of my knowledge and understanding.
/1Fi� ITLY� A�Zlfi / �J
Print Owner's or Authorized Agent's Nair a(Electronic Signature) Date
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 eol 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
wwvv mas;eov'oca Information on the Construction Supervisor License can be found at www.ntas�
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. ff.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type ofcooling system Enclosed Open
3. "I'otal Project Square Footage may be substituted far"total Project Cost"
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* '\ The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
' www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: NIVf_X ((Ry loI, AC'ral9 S
Address: LiAL#,�
City/State/Zip: ✓] Wl/k OI `)0 Phone#: ���- j�j '(��/
Are you an employer?Check the appropriate box: Business Type(required):
1. I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] $• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy information.
Insurance Company Name:ALL &1L fffAl[) W 5, CO
Insurer's Address: n 6S WPrW/j'
City/State/Zip: ¢6(Q ✓� 7 j �
Policy#or Expiration Date: /0 t7
Attach a copy of the workers'compensation policy declaration page(showing the policy num er Ad 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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.
I do hereby hfy, under the pains and penalties of perjury that the information provided above is true and correct.
Sil=.nature: vl ll Date: I/—kll
Phone#: 97L - Q'V/69
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
J
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold,the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its:political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line. -
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
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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 District
Address of Property: 17Warren tret
Name of Record Owner: Deborah A Jackson
Description of Work Proposed:
Reroof in-kind with 3-tab asphalt shingle in block.
There will be no changes to the color, material, design, location or outward appearance of the house.
Non-applicable due to being in-kind replacement.
Dated: October 17, 2016 SALEM HISTORICAL COMMIISSION
' IO
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.
Once completed,please submit a photograph(s) of the final result(maximum of four-i.e. one photograph of
each affected fagade).
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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Construction Debris Disposa/Affidavit
(required forall demolition and,.renovation workj
In accordance with the"edition of the State iWMi W code, 780 CII^ Section 111.5 Debra
and the prO*Jons of MGL cW,S 54, MOW Pemit A is issued with the
condition drat the debris resuf ft from this work shah be disposed of in a properly licensed "
waste deposit facility as defined by MGL c ill,S isK
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facliity)
Signature of applicant
Date
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 District
Address of Property: 17 Warren Street
Name of Record Owner: Deborah A Jackson
Description of Work Proposed:
Reroof in-kind with 3-tab asphalt shingle in block.
There will be no changes to the color, material, design, location or outward appearance of the house.
Non-applicable due to being in-kind replacement.
Dated: October 17 2016 SALEM HISTORICAL COM.MIIS�tSIIOON
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.
Once completed,please submit a photograph(s) of the final result(maximum of four-i.e. one photograph of
each affected fagade).
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.
/ q F