4 CROSBY STREET - BUILDING JACKET The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
h MUNICIPAITI'1'Massachusetts State Building Code. 780 CMR. 7 edition USE
Building Permit Application To Construct, Repair. Renovate Or Demolish a Revised Junum
One- or Tno-Fornifv e it
This Section r Official Us4 Only
Building Permit Num r: I RatfAppli :
Signature:
Building Commissioner/Ifispector of Buildin , Date
SECTION I: SITE INFORMATION
1.1 ro rty Address: 1.2 Assessors Map & Parcel Numbers
C1A-<6 r�
I.1a Is this an acM pled street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L e.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public al ❑ On site disposal system ❑
Public ❑ Private❑ Check if es❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' f Record•
Name(Print) Address for Service:
54/9
I
Signature Telephone
�
SECTION 3: DESCRIPTION OF PROPOSED WORK (check al at apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) Irl Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'- v /
(PiJ ✓J i �i�/..j / /'/i/5� A ors iJi/-r `l/
SECTION 4: ESTIMATED CONSTRUCT IO COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ wilding Per Fee: $ Indicate how fee is determined:
❑ Standard City/fown Application Fee
2. Electrical $ ❑Total Project Cost(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: /—r-
5. Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amount: Cash Amoune
6. Total Project Cost: $0�3 �6 ❑ Paid inFull ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder List CSL Type (see helow) � -
(� T Desch (ion
V4 Address U Unrestricted(u to 35.000 Cu. Fr t
i\ R Restricted 1&2 Fumil Dwellin S
�l Signature Masonry Only
R Residential Roofing Coverm
Telephone S Residential Window and Siding
F Residential Solid Fuel Bu nm :\ rliancc In.(,dlation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC /is ---?, 3 �7
HIC Com any Name or HIC Registrant Name Registration Number
�o%t�fi/rl ls/1�,ti3
Address g�g1922.,5_ Expiratiod Date
Signatur C!� Telephone
SECTION 6: WOR S' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.5 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it)provide
this affidavit will result in the denial of the Issuanc,e,66f 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statement and information on th ' regoing application are true and accurate,to the best of my knowledge and
behalf. f
Print Name s(/
Signature of Owner or Authorize)Agent Date
(Si ned under the sins and nalties of r'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 not have access to the arbitration
program or guaranty fund under M.G.L.c: 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11O.R6 and 11O.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics.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 cowling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
• 4 CROSBY STREET a '
Richard T. McIntosh
1 Salem Green February 6,1984
Salem,Ma 01970
Elizabeth A. Bartlett
4 Crosby Street
Salem,Ma 01970
Dear Ms.Bartlett:
An inspection of your wood burning stove made by this
Department, has revealed the following:
1. There is no cleanout at the bottom of the chimney(required)
2. There is no draft stopping at the 1st floor level on the
chimney (draft stopping is required at each floor)
Before a permit can be issued for the solid fuel stove,these
items must be corrected.
City records indicate that a Certificate of Occupancy was never
issued for 4 Crosby Street. There have. been no inspections made
by this Department, relating to the house construction. This must
be attended to.
Very truly yours,
��, � � < < ti ✓ , r:f,
Richard T. McIntosh
Inspector of Buildings
RTM:mo' s