0056 WASHINGTON SQUARE SOUTH - BPA-10-360 a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
J j Massachusetts State Building Code, 780 C'MR, 7a'edition OF SALEM
Revised Junrmn•
Building Permit Application To Con ct, Repair, Renovate Or Demolish a
One-or Tw X mils Dwelling
This lion For Ofrcial Use Only
Building Perrnil Num be Date Applied:
Signature: / b
Huilding Cummissi fns tar of BuilJings Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted Slreel?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot A=(sq 11) Frontage(11)
13 Building Setbacks(11)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Informadoa: 1.8 Sewage Disposal System:
Zone: Outside Flood ZoneT
Public O Private O — Check if es0 Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: c// II II II�� CC'`` IIII
Vt InJGStliN_(r0'1') �S�yGft &[Tl�h
e(Print) n Address for Service:�
/� �-7 F y r-239
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work': �- c
SECTION 4: ESTIMATED CONSTRUCTION COSTS ` c�V G
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building Is p I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
?. Electrical S O Total Project Cost(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S G O I (�� O Paid in Full O Outstanding Balance Due:
sue" "`
SECTIONS: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor(CSL)
License Number Expiration bate
Name of CSI.- I lulder list C'SL Type(see below)
t Description
:address U (InmtricteJ u to 13,000 Cu. Ft.
R Restricted Id2 FamilyDwellin
Signature M M Only
RC Residential Raclin Covcrin
felephone WS Residential Window and Sidin
SF Residential Solid Fuel Sumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or 111C Registrant Name Registration Number
Address Expiration Date
Signature 'telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL f 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..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONT(`RACTOR APPLIES FOR BUILDING PERMIT
I }J CAN S , as Owner of the subject property hereby
authorize C to act on my behalf, in all matters
relative to work authorized by this building permit application.
e //6- 1y /aa /(3
Si um of Owner Date
SECTION 7b: OWNER[OR AUTHORIZED AGENT DECLARATION
1 ,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.
Prim Name
_ Signature of Owner or Authorized Agent Date
(Signed under the pains 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.W have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I MRS.respectively.
2 When substantial work is planned,provide the information below:
Total [loon area(Sq. Ft.) (including garage, finished basement/artics,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
). "Total Project Square Footage" may be substituted for"Total Project Cost"
• �0
�rnNsvo
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑/ Construction ❑ Moving
1� 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 Washington Square
Address of Property: 56 Washington Square Srnrth
Name of Record Owner: Duncan Hsu
Description of Work Proposed:
Demolish and rebuild front chimney to replicate existing. No changes in color, material, design, location or
outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: October 14, 2010 SALEM ORIC OMMISSION
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.
CITY OF SALEM
PUBLIC PROPRERTY
„�,.
DEPAKT'NIENT
11 'I'3.-I;.•);Ij I \C: 'i 7.4 '4:-'IS41E
Construction Debris Disposal Allidavit
(requited li,r all demolition and renovation work)
In accordance N Itll file sixth editloll of the State Building Code, 780 CN1R section 1 11.3
Debris, and the provisions or MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resultin.- from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 1 L S 150A.
The debris will be transported by:
1 numc of hailer)
he debris will
be disposed
(of in
(nainr ul laci rty)
InJdress ul I�cililVl �+ /1^/
�iguawte of permit.ylpheaut
.Ina
I
C
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPARTMENT
VArM I30 WAUW rM ftMW 9 s,Aufa VAsuotisaM019V
r1L 978-7459S"• F.%X 9'5-7469646
HOMEOWNER LICENSE EXEMPTION
Pleaw "I
Date /0 14 all/U
Job I oesti tdcs h i & S9 �i yrh , SGIe✓n, M�
Home Owner Address sen aS GlatX/P_
Home Owner Telephone 972 412-
Present Mailing Address S6 4/ SH -z,; �'3 zLty2 Sow, S Q w, M1
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a fort acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE 4 ,— '-7- C
APPROVAL OF BUILDING NSPECTOR
See other side for state code