0047 WASHINGTON SQUARE NORTH - BPA-14-853 The Commonwealth of Massachusetts
V Board of Building Regulations and Standards ECEMOF
M Massachusetts State Building Code, 780 CMR INSPEC 10NALARVICES
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demoligb' A R 24 A S 0
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: *Dat
Building Official(Print Name) Signatu
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
S �
Iwre-
1.ra Is this an accepted street?ye no Map Number Parcel Number
1.3 Zoning Information: 1� U J 1.4 Property Dimensions:
Zoning District Proposed Use t• Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
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 n Owner'of Record:
r iaLr ara Sch,.^Cr z .S'i+ta„r i4✓a- G 57'
Name(Print) City,Srate,/.,I
4 WTfA:. A, 5'7 y-
No.and Strect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
C hum C, I as
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ _ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ /0 ❑Paid in Full ❑Outstanding Balance Due:
�IL� � P 5rf1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r _""/l GS - osNr�s
fsp 2 n License Number Expiration Date
Name of CSL Holder
,r List CSL Type(see below) l.J
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
Ci y fown,State,ZIP/ M Mason
ry
RC Rooting Covering
WS Window and Siding
p _ / SF Solid Fuel Burning Appliances
l �'�' S,3 1- �6T �A✓.� 4 " !�n r✓urG... , rvn� 1 Insulation
Telephone Em address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
tW as- 1,-
A— HIC Registration Number Expiration Date
HIC C mpany Name r HIC Registrant Name 11
.�F ✓�R i�� � 4j Pn r,. , cry
No.and Strecl s, Em it address
1'-e.+ .� 1�- o ty 6�
Cit /Town, State, 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,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this appl cation is true and accurate to the best of my knowledge and understanding.
y`ti Print Owner's or Authoriz d Agent's Name(Fleclmnic 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 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.aov/dps
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basemendattics,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"
CITY OF SM-ENI, 2AxsSACHUSE-1717S
j BUILDING DEP.\RIMEINT
120 W.1SHLNGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.s-x(978) 740-9846
KI\[BERI EY DR DRISCOLL
vfAY THOAtAs ST.PiFAR&
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( Please Print Legibly
Marie (Busine,%<Orgmtizaiom'Individunl):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: 'rype of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or pan-time).
have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'camp. insurance. 9. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption pir MGL I I.❑ Plumbing repairs or additions
myself. [,so workers'cutup. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees.[No workers' j;,❑ Other
cutup.insurance required.)
•Any appkanl that checks but#1 most aleu rill out the section below showing their worker'eompenwtiun policy intitrmalion.
'I tumeuwners who suhmil this affidavit indicating they arc doing all work and then hire outside eennicans most suhmil a new affidavit indicating such.
:Commctuts Ihul check this box mtm anachod an additional 6hwl showing the name of the subcontractors and their woken'comp.policy infunnmion.
I ant an employer that is providing workers'conlpeasallon insurance jar my employees. Below Is die policy and fob site
information.
Insurance Company Name:
Policy 4 or Self-itet. Lic. #: __.._ Expiration Date:
Job Site Address: City/State/Zip:
Auach 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 cf MGL c. 152 can lead to the imposition ofcriminal 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
Investigaions on tic DIA for insurance coverage verification.
I no hereby certify under the pains and penalties'of per/ury drat the iuformadat provided above is true and correct.
Sl l`nntllrC' Datd'.
Phnnc 1:
Official use only. Do not write in this area,to be completed by city ur town official
Ciry nr Town: __._. .__ Permi6rLicense#
Issuing,Authority(circle one):
1. Board of Ileallh 2. Building Department 3.Citylfown Clerk 4. Electrical luspectur 5. Plumbing Inspecmr
6. Outer
Contact Person:_ _—. Phone #:
I
CITY OE si1L.E1,t, A-mACHUSETTS
?/tAil1� BULIX) IG DEPARTU&NT
120 WASHCVGTON STREET, 3'a F-OOR
TEL (978) 745--9595
F.ux(978) 7•;0-9845
KIMffiF12L.EY DttlSCOl1.
AAYO11 T Hobtl.4 ST.PtEajM
DIRECTOR of PL is PFtOPERTY/HCILDLN<; CONNISSIONER
Construction Debris Disposal At'fidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, 'i d die provisions of N101, c 40, S 54;
Building Permit t« 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 IGL c
111, S 150A.
The debris will be transported by:
y
(name of hauler)
'fhe d{{e/bris will be disposed of in
04-,-T;
(name of facility) —
(adJre s or'r�tilitYl
i
signature of pet Mir applicant
htc
�ONOl Commonwealth of Massachusetts '
3 ~� o City of Salem
Inspectional Services
120 Washington St,3rtl Fbor Salem,MA 01970 Phone:(978)745-9595 x5641
Application For Building Permit (One- or Two- Family Dwelling)
Permit No# {" ,TB 14 853 i1 tst f3 GIEE,C �
�, „I Date Applad:" 5I,1/2Q14 t l�s kElk�p g E `
It
It#� :iI'>IiI I '�I'{Ili jt�tk� I�EfttIiE Slkilii k{IIiI�'E. 4 N
Building Official (Print Name) Si nature k IIIEI{ aa'
.,n Itt� I „ �• ,kin,�� tkrnntt n,GHjIkG , Ic gE(IEEII�I( 9 lIIII ���l!i ;{ IIIIkII! ! Ilk�l�E t Date Issued k
'
III "riEIEkIIi ,jli1 Iliutr' 1 I ll'jIIS1 CTION 1 tSITEINFORMATIONG! II
' IIIIII {�kt�Illlt` � I
1.1 Property Address 1.2 Assessors Map& Parcel Number
47-U7 WASHINGTON SQUARE NO 35-0075
1.3 Zoning Information 1.4 Property Dimensions
0
Zoning District Proposed Use Lot Area Frontage(ft)
1.5 Buidling Setbacks (ft)
Front Yard Side Yard Rear Yard
Required Provided Required Provided Required Provided
0.00 0.00 0.00 0.00 0.00 0.00
1.6 Water Supply: 1.7 Flood Zone: Outside Flood 1.8 Sewage Disposal System
Zone?Check if
Public Zone: yes_ Municipal
IM2A�dlali`:k{! ,11 r. ,xlil� kkr 'i I�I11Ik'„ SECTION2 �Pi�OPERTY'OWNERSHIPt'
Owner of Record
SWARTZ BARBARA 47 WASHINGTON SQ NO SALEM MA 01970
Name Address
(978) 522-5189
Phone Email
jAiIII ,,SECTION 3t DESCRIPTION OF PROPOSED WORK, I ;
a
Permit For: Fireplace/Chimney
Brief Description of Proposed Work:
REMOVE & REBUILD CHIMNEY COMPLETE WITH MISC ROOFING WORK
pl " ,bl! jrEa.SECTIpN14�iEST1MATE6CONSTRUCTION COSTS/PERMI7iFEES; it i{N
Total Project Cost: $10,538.00 Payment Date Amount Paid Check No
Total Permit Fee: $70.00 5/1/2014 . $70.00 18243
Total Permit Fee Paid: $70.00
1A „., - :- .............�,,. ! T{
!7NTHIStIISk-NOTlilA';,PERen,;9,,,.M, I1nT3�{nn,x0 �rk{k1i„Ir�!orw® {��tlIRt're'EmI!+n!j
° °` Commonwealth of Massachusetts
y of
°' �qy City Salem
X
r ° Rr Inspectional Services
RInn rrc 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
ECEIPT
Building Type: Single Family Condo Existing Proposed
No.of Floors/Stories(include basement levels&Area Per Floor(sq.ft.) 0 0
Total Area(sq.ft.)and Total Height(ft.) 0.00 0.00 0.00 0.00
H 'i, rX i '` Ii{lI'° SECT) 1 5. COMSTRUCTIi SEii ICES + e�s{X .. �Sillt 1 'BiliS 4t„ ti±il}lei,igsn IOfln�e i IIIIrI SN Anat ftl!,S Ih
ltSOwa �I� .III 1 4 t•ia.�ii
Dl ,.,;c;lI II,SECTIQ 8. WdhK RSIFCOMPEN$ATION INSt1"NCE",AFFIDAVIT-*I
.d "U
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 On File?, . False
i=Id.111
� { N'7a:'OVYNe AUTHO I ATION TO IE COMOLETED WHEN {II{+lilgr"* h1llpiihwlN
' ^,Xi,70Wr#ERS'AGE Tt)gCONTRACTORAPPLIESFORBUILDINGPERMIT�1i1, " uG 'IX tflj
' I � n�#,tiii
I, as Owner of the subject property hereby authorize Aspen Roofing to act on my behalf, in all matters relative to work authorized
by this building permit application.
SWARTZ BARBARA 511/2014
Print Owner's Name(Electronic Signature) Date Submitted
SECT1 ."OWNER-_ORAUTHOR...IZEStA4N?� GENT DECLARATION
P
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.
SWARTZ BARBARA 5/1/2014
Print Owner's Or Authorized {Agent's Name(Electronic Signature) Date Submitted
IM1ii Xn ii; k` E
r•X S# ,i.iX Elli,�XU� l3l 6TES•3SkIII II�iI{l17�1" , 3" '' ilx.y..l film IE�
I kii l 1 h llp�.,. f ,iil v hilt 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 HIC Program), will got 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.gov/oca Information on the Construction Supervisor License can be
found at www.mass.gov/dps
When substantial work is planned, provide the information below:
Total Area(sq. ft.) 0.00 Type of Heating System Number of half/baths
Gross Living Area (sq. ft.) 0.00 Type of Cooling System Number of decks/porches
Number of Fireplaces Room Count Enclosed/Open
Number of Bathrooms 0 Number of Bedrooms 0
l P!lIslE il iE{lll fttiiPi,nx"lA Mi liBlnx� X, lilHChi""XE`XPtM
';A�PERMIT°TH� ' NOTaa�^ S E1 iIIFF!F�
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
O 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: 47-49 Washington Square
Name of Record Owner: Barbara Schwartz & Ralph Countie
Description of Work Proposed:
Rebuild the existing chimney in-kind. There will be no change to the chimney material, design, or color.
Non-applicability due to work being in-kind repair.
Dated: April 30, 2014 SALEM HISTORICAL COMMISSION
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.