165 FEDERAL ST - BUILDING INSPECTION 45 5 20 w qq
GEIVt
fheCommonwealthoft�lassac eft aDNAL SERVICE CITY O]2011 Board of Building Regulations an t SALEM
0 � Massachusetts State Building Code,
17�8�0�CMR_I p Reviso J'jr
�Q Building Permit Application To Construct, Repair, RtlwdlXd(h�erholi a2
One-or Tivo-Family Dwelling
N This Section For Oficial Use Only
Building Permit Number: Da pplied,
Building Official(Print Name). Signature•: Date
SECTION 1:SITE INFORMATION
1.1 Property Address: J1.4
.2 Assessors Map&Parcel Numbers
t' �.
I.la Is this an acce ted street? es Li no op Number Parcel Number
1.3 'Zoning Information: Properly Dimensions:
District Proposed Use t Area(sq R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard - Site Yards 5sitedispoial
Yard
Required Provided Required Provided. RequireProviJed
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewagetem:
Zone: _ Outside Flood Zone? Munici ❑ s stem ❑PublicII Private❑ - Chk If es❑ - � � y
SECT[ON2: PROP6RTYOIVNERSHIPt'
2.1 Owners of Record:
kraf P tr?ra 1X"(219
.tRtlrrte(Print) City,.State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSEDWOW(check all that apply)
New Construction❑ Existing Building 13 Owner-Occupied ❑ Repairs(.) ❑ Alteration(s) l7 Addition E3
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESThNATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and hlaterials)
I. Building $ j 1. Building Permit Fee:$ Indicate how fee is determined:
❑Stmdard City/Town Application Fee
2. Electrical $ ❑Total Project Cosh(Item 6)x multipliers s`
3. Plumbing $ 'k Qther Fees: $
4.Mcndmnical (HVAC) S List:
5.i\lechanicai (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6.'rotal Project Costf7s E3Paid in Full 13Outstanding Balance Due:
(Y\fa ,L_AE�o I t�ZA:1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) LC 6 qy, L'f j , 7
S Awe A&J `� License Number Ex�piration Dale
Name of CSL Holder A List CSL'rype(see below)
Type Description .
No.and Street
U Unrestricted(Buildings Lip to 35,000 cu. Il.
u/�4e 4 ,/CG. 01Q6 9 R Restricted l&2Runity Dwelling
6tyfrown,Stale,zip M Masonry
RC Rooting Covering
WS Window and Siding
c SF Solid Fuel Burning Appliances
7 A 317 1 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home"I�mproovement Contractor(H IC) ��y-
("o �'ki-e Y� / �ir/J�77"(LL�7�A-Q HIC Regisuauon Number Expiration Date
IIIC Company Name
�or ll C RegislJr�ai /1 �,.,��� �y�i
Z12
No.and Stry;tUw` � & GI Q�p 97� �I7 �9L Email address
Ci frown.State ZIP `/ !• l Telephone
SECTION 6:WORKERS,COMPENSATION INSURANCEAFFIDAVIT(M.G,I 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........O
SECTION 7a:OWNERAUTHORIZATION:TO BE.COMPLETEDWHEN! -
OWNER'SAGENTOR I NTRACTORAPPLIESFORBUILDING. ERMIT
I,as Owner of the subject property,hereby authorize S ( '
tqJ{fact onp [ion.my behalf,in a matters relative to work authorized by this building permi
t applicat /
Print Owner's Name(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.
Print Owner's or Authorized AgenVs Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
__(not registered in the Home Improvement Contractor(HIC)Program);will LIQJ have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other'Important inform—iion on"lie HIC-Pe ram can be-forma at- - -
www mass.eov:'oca Information on the Construction Supervisor License can be round at w+etv.nmss._ov'dns
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) N (including garage, finished basemenVattics,decks or porch)
Gross living area(sq. fl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype of cooling system Enclosed Open
3. "Total Project Square Footage may be substituted for-rutal Project Cost"
4
The Commonwealth ofMassachusetts
Department oflndustriduccidents
I Congress Sweep Suite 100
Boston,M.4 011141017
wwwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eledricians/Plumbers.
TO BE FILED 87TH THE PERMITTING AUTRORITY.
Applicant Information Please
Name(BosLoess/Otgmdntlon/lnd videal): '
Address: LI -7 /•c c,i'I/'(/a rx 196AZ/
CitylstateiZip: w l c bone#:
Are you an employerr Check the appropriate box: r
Type of project(required):
1.9K=a employer aiPo_ employees(full aod/orpart-time).:
l am a sok m ` and Lave uo Z ❑NeW con
2. fmIOn
❑ pwpridor pemeralup empbypos"40g forme io 8: iodelin .
anyespaeity.'[No wakes'gyp inaaatiee requ6ed.)- .
3.[]!em a homeowner doing an work myself.fNo workers'comp.insurance regioned]t 9. ❑1kroolition"
4.Olax.ahomeowner and willtx Lviog cmtraaanmcondo 4 an Node onmy property. Iwsll 10❑Building addition-
gimme that all comacoms either how wohkes'compeawtion iosmaece or are sole 11.0 Electrical repairs of additions
pmpictms V*on emplorm. -
5.❑Ism a semml Connector and Iheve hired the sub-eonuamme oaten on we amched slxat. 12.0Plumbing:iCpBus or additions
There sub�contracton have employceand have woxkm'comp.Meacen--r M oltoufrepairs.
6-E]We are a corporation sod its officers have eaemised die irog a of exemption per MQ:c. 14.❑Other
152,§1(4),and we hate no engdoyea.(No workers'con*inmmancerequired) - -
'AnyapPlicatthat chechbei flnumn also 611 but the section below showing theirwivkma poLry ion} atipn.
t Homeowner wLo submit Pols atfidavh... .. .,
tndh�8�Y are doing as wmk�®d Woi tine oetride eo�eras muse satonit anewaisdavit iodieaerhg such:
1Conwuma Poo check"box noun mhiched ao ndditionel aLeet oho
wins Pos pie O}'ace'sub-connBams and ante wliedicim not comics have
employm Hocsab•coacf. have employee,theymustpsundotheir workms'comp.Poluy mugl>Q.
lamamemployertlsotirproyidingrrothers'comppraationinsrrrancejormyesiplgyees. BeJaivisfhepoliryandfrrbsite
informaaton.
Insurance Company Name.___/ , bel L
& l
Policy#or Self-inn.Lie.#//iUlnQ f,?l-C V` �D /. Y— D!1 y Expiration Date:
Job Site Address: /'?l P, 1 Z J. !�i lv,m lli , CityAtate/Zip: U!C� /�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and exphrltton date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by line up to 51,500.00
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.A copy of this statement may be forwarded to the"Office of Investigations of The DIA for insurance
coverage verification.
Ido hereby certify rvmde the ainsairs and penal les of erfnly that the information provid/ed/above is owe and eonmt,
Siaaatme• s,L2/'�'�'� ��- Dag•
Phone#: g 72 ,3�
Official use only. Do not write in this area,to be eoerpleted by try orawn offmial.
City or Town' Permit(LICanse#
Issuing Authority(circle one):
1.Board of Health 2.Building Deparmient 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thea 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 corrmtonweabli 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 sub-contractors)name(s),address(es)and phone number(s)along with thea certificate(s)of
insurance. Limited Liability Companies(LLQ 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 sore 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 question regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insuredcompanies should enter thea
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 pemmittlicanse number which will be used as a reference number. In addition,an applicant
that must submit multiple pemnUlicense applications in any given year,need only submit one affidavit indicating coram
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."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 frilled out each
year.Where a home owner or citizen is obtaining a license or pemrit not related to any business or commercial venture
(i.e.a dqg license or permit to burn 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, Suite 100
Boston,MA 02114-2017.
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
4 L
CrTY OF SALEg MASSAQiusEm
BEaD7NGDEPAR7MENr
120 WA9MW7 IS7REET,3PRDM
IkL(978)745-9595.
KIPAX(978)74D-9846
1vJSERLEYDRiSODII.
MAYOR TTrR�STYMME
Dnmcrca cFpuBmcrxcmmy/BWDmomnm9omR
Construction Debris Disposa/AffAdavit
(required for all demolition 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 coq S 54; Building Permit d is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
�Co�2w�S •Tra�S �er .5�7� n
(name of facility)
(address of facility)
Signature of applicant
Date
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 619-5665 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
Address of Property: 165 Federal Street
Name of Record Owner: Kate Pratt
Description of Work Proposed:
Repair/replacement of wood clapboard on left side of house,painted to match existing. No changes in color,
material, design, location or appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: November 16, 2015 SAL T CAL 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.