6 WHITE ST - BPA-10-347 CHANGE FP TO WOOD STOVE IThe Commonwealth of Massachusetts o Town of
Board of Building Regulations and Standards
Massachusetts State Budding Code, 780 CMR. T"edition Building Dept
;III Building Permit Application To Construct. Repair, Renovate Or Demolish a
1J One- or Trr urruh Duelling
This S ciao For Official Use I
Building Permu um�bbe�er:,,, a lied: qq
Signature: """"� /
Budding Comrrussrone mitector of Buildings Date
SECTION is l INFORMATION
1.1 Properly Addreu III Assessors Map 6 Parcel Numbers
6 L��� s+ �I to J 1a
1.I a Is this an acce led street''yea no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Los Arc&(sq R) Frontage(A)
I.S Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided I Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site dis sal system O
Public O Private O Cheek if sO P po Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 wrier of Reeor
a cSJt �. l� JF rr —
Name( int) Address for Service:
r1-7t-- �-7t--
Signat Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O 1 Addition O
Demolition O I Accessory Bldg. O Number of Units_ Other ! Specify:
Brief Description of Propos Work':
&eryla„(e, 7ern -�re �>✓ nSS G,,
t L ,�t-a n'2,caJ z 1b '- y S J✓gz
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
labor and Materials
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electncal f ❑Total Project Cost'(Item 6)x multiplier x
J Plumbing $ 2. Other Fees: S
4. .Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 0 Paid in Full 0 Ouwandmg Balance Due:
r
T
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
1, T
A50rs EAD �� License Number E.puation Date
Nyoe of CSL Hylder n List CSL T
YDe Ix'e Iwlow) s
Type I Description
AJz
U zUUnrestrictedu a 13,1N)0 Cu. Ft.
d
R I Restricted 1!2 Family Dwclhn
So lure M .Mason Only
[pQ�3-239 —63677 RC Resldenual Rooftn Covenn
Telephone w'S Residential Window and Siding
SF I Residential Solid Fuel Summit Appliance Installation
D Residential Demolition
5.2 Registered Home Imgrovemcut Contractor(HIC) 5�h
� iA SIYn 1�Ar1 4� S'
HIC Company Name or HIC Repsu t Name Registration Number
Add
at
� 7C( GF3�7 Expiration Date
Si tune Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. c. 152.f 2SC(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....... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
Fstmnedunderffly
ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. , as Owner of the subject property hereby
ze to act on my behalf,in all malters
e to work authorized by this building permit application.
re of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
statements and information on the foregoing application are true and accurate, to the best of my knowledge and
A S5 �
me
e of m or Authorized Agent Date
nder ains and penalties ofperjury)
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 Id have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important infonnalion on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110.Rl,respectively.
2. When substantial work is planned.provide the information below;
Total 0aors area ISq. Ft.) (including garage, finished basementlattics.decks or porch)
Gross living arcs ISq. FL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of healing system Number of decks/ porches
Ts Pe of coolingsyctem Enclosed Open
t Total Project Square Footage"may he substituted for 'Total Project Cost'
CITY OF S.U-E.`t, ,NA-kSSACHL'SETTS
BU DLNG DEPART.NIEVT
120 WAS LNGTON STREET. 3w FLOOR
TEL (978) 745-9595
F.%X(978) 740.984
1C1.,BERI.EY DRISCOLL Tl one ST-FtEmm
MAYOII
DIRECTGR OF PC BLIC PROPERTY/HCQDLVG GOMNt1SSIONER
Workers' Compensation Insurance AIIldavit: guilders/Contractors/Electrlclans/Plumbers
luplkant Information Please Print Legibly
Vault ousine+ or ttatiomin.bv,dual): (. I.�i, '.t,
l t:N �
Address: hlu &-�- Poe
City/State/Zip:Afty fr. A)A 0-30:30 PhoneN:
,%re you to employer'Cheek the appropriate boa: Type of project(required):
1.❑ I am a employe with g. ❑ 1 an a general contractor and 1
employees(full and/or pan b
-time).• have hired the sub-contractors 6. ❑New construction
2.g I an a sole proprietor or partner- listed on the attached sheet : 7. ❑Remodeling
.,hip and have no employees These sub-contractors have t. ❑ Demolition
working for me in any ca acetY• workers'comp.intauaao
9. ❑ building addition
(No workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) ofAcen have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. C. 152.410),and we have no 12.0 Roof repairs /
insurance required.)t employees.two workers' 13. Other
comp.insurance required.j
•Any applinm thin chawks hoe el mum also fin cad 1M tKtiea hslw rhowittg their soften'compmlogl n puliry infumutloa
'I Icswwren who su6trtit this aHldsvit indinrina they ar Joins all work and thm him ismidn es r a lore ttttmt suhmh s now allhkeit miliss iq reek
:f%,mm-wm,that cheek this hie mud anwhad an 3"iiunnl Own showing this none dlhe eah.e'enlrilern and think worker'omits.policy iwfmrduaa.
/urn an employer that!r providlnR workers'compensation lnastrowr fer any employees Nelvw/s the PWlc7 andM si&
injormatfon.
Insurance Company Name:
Policy N or Self-ins. Lie.N: Expiration Data.-
Job Site Address: 6 i e�G)�c' g rs2 City/State/Zip: S ufC liM VWC
,knach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dab).
Failure to secure coverage as required under Section 2'5A of MGL e. 152 can lead to the imposition of criminal penalties of a
f ne up to S 1.500.00 and/or one-year imprisonment,as well as civil Penalties in the form of a STOP WORK ORDER and a fits
Of up to 5230.00 a day against the violator. Ik advimod that a copy of this statement maybe furwarded to the Office of
Inresntgutiuna ul'ilia DIA for insurance coverage verification
/do hereby ratify milder fhapaigyandlienuftles of perjury that the informadon provided above is true vied cornea
r Dale:
Ofrittl sae Wily. De nor,write in this free, to be.ornpletd by city of/awn o/flcivi
I
City or ruwn: _ Permit/l.lcense M__.
i
Muing Aulhortly (circle one):
1. Ituard of 11ea1th 2. Ruilding Department 3. C'ilyfrown Clerk J. Electrical hispcclor 5. Plumbing Impeetor
6. Other
l„wacl Person: _ ._. _.. PhoneN'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
4 D
. I
I�I
Fri:978-7+ -9;9s . r.\r:9721-7+0-984e
Construction Debris Disposal Affidavit
(required 1'ur all denwlition 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
12
(name of haultrl _
The debris will be disposed of in
1x:r(t1 �✓"th��'s'r_ s�u ova
--T (name ofTaci I
lrrl /1/ 1 (
(address of t'aciluy)
.ignrure of Ix
nnit applicant
date
NATHANIEL'S LANDING CONDOMINIUM ASSOCIATION
6 WHITE STREET
SALEM, MA 01970
■ k 4 �
I tending
October 26, zoog
To Whom this may concern;
The trustees of Nathaniel's Landing Condominium Association approve of the installation and
use of a wood burning stove in Unit#z provided it conforms to all local, and state regulations
regarding safety,yearly maintenance and appropriate insurance requirements.
Sincerely,
Date: f 6 Z C� eI
Carol LNaranjo
President, Nathaniel's Lan ing Condo Association
6 White St. Unit y
Salem, MA oi97o