27 R HARDY ST - HOOPER HATHAWAY HOUSE - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
k4J Massachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
y\
Building Permit Application for any Building other than a 1- o - am4availab
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION (Please indicate Block# and Lot# for locations for which a street addres4isnot
JV
No. and Street City /Town �-17L rAJ Zip Codeo/9` 0 tame of Building
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Buildinga, Repair KI Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: _
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Z/
Is an Independent Structural Engineering Peer Review required? Yes ❑ No L'D/
Brief Description of Proposed Work: r�� R(Jf to e Lt 'tT'4R Gj//MAJFV F:Rn/Vt Roo / /il/
-� L 6 e&S NO T7
U ce 1-16?F-15 ,
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed UseGroup(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 14 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility ❑ Special Use❑and please describe below:
Special Use: 114 u-5 F us /,-/ G S G
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA IB ❑ IIA 13 IIB ❑ IIIA ❑ IIIB ❑ 1 IVO VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Floud Lune ❑ Indicate municipal ❑
A trench will not Lie Licensed Disposal Site❑
required ❑or trench or apecity;
Pricnte ❑ or indentifi Zone: or onsite system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I Ii>t,)ri.-Cnm Ia i—ii to ILoa W, Prnn•��:
Not Applicable ❑ k Structure acithin airport approach area? Is their rem mew completed?
ur Current to Build enclosed ❑ Yes❑ or No❑ Yes ❑ Nb ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition nt Code: Lbe Group(s): Tcpe of Construction: Occupant Load per Fluor:
Does the budding contain an Sprinkler System?: Special Stipulations:
_ 2 G4b6
SECTION 9: PROPERTY OWNER AUTHORIZATION '
N me and Addresss )t P operty Ovnerr _ n /
/�'1 - j�BuJe j�P_ ✓B� fJ- 41 &> eJB✓4/ c,� ac /e/!7
Name(Print) Nu. and Street City/Town Zip
Properly Owner Contact Information:
N Ir ,-, a.2d
y
Title Telephone No. (business) Telephone No. (cell) e-mail address
If ap�licable, the properlyowner hereby Ah urizes'/
Name Street Address Citv/Town State Zip
to act on the pro pert vow ner's behalf, mail matters relative to work authorized by this buildin • permit a licatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,000 cu. ft.of enclosed s Lace and/ur nut under Construction Control then check here❑and skip Section 10.0
10.1 Registered Professional Responsible for Construction Control
i
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
RIC UK > OM S
Cump any Name: e C . I p ^I 3 9 L1/C.
(2 Fs'7"OR J3Tl E�,n� �nA A 50n15 J I Ol r/ '7
Name of Person Res onsible for Construction License No. and Type if Applicable
5,�,(,l G/MERic k � 0,910417
Street Address 1 City/Town - State Zip
X63,2fpw6 207-2- - LIG� S
Tele hone No. (business) Telephone No. (cell) f10U54F e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the M-K Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor o � S00
and Materials) Total Construction Cost(from Item 6)=$
1. Building C M F $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$,- SY
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ - Enciose chick payable Lo
6.Total Cost $ Z.Z .5t�� (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
RICHARD /1,TRONs - RE ,(0 ouifirK W--02- aR06 i3
Please print and>in nan e TitleN AL Telephone No. Date
Street Address City/Town State Zip
M =9 H
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SALEM
4,. .�,L PUBLIC PROPRERTY
DEPARTMENT
,t�rv.N'I\ rNhl. 11
\I r a Nt
12C W,%It ZING 10.5 t Y LL 1' • S.AI Ili. MA1%%s i u a i is.197.
Ie.l. 'JyL,'1i•Ij`+$ is I sa 979-74i: )346
wurkers' Cumpensation Insurance ifkfffduxit: Builders/Contractors/Electricians/Plumbers
is1 tlicant Infl)nnalion Please Print Le ihly
Villnd Ilio.uka1)r;;anp+r.uinn'Indn,.luall:
1ddress: /,w 77y/r rr,�l !Yd
Ciry,.Stata%ip o�iwGN�''rc/� �!�. eyoY� Phunr ;,
.\re)uu an employer'! Check the appropriate box: Type of project (required):
1. ZI .,,it a employer with V d. ❑ 1 ten a general contractor and 1 0. ❑ New construction
eny>loyccs(full and'ur port-time).• have hired the sub-contractors
2.❑ f am a sole propricu>r or partner- listed on the anachcd sheet. 7. ❑ Remodeling
ship and have no cmpioyces These subcontractors have B. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9, ❑ pudding addition
No workers' cote insurance 5. ❑ We are a corporation and its
I p•
required.) officers 10.C] Electrical repairs or additions
officershave eaa'ciseJ their
3. ❑ 1 and a hnmcowticr doing all Awrk right of exemption per MOL I l.❑ Plumbing repairs or additions
myself. [Ko workers' comp. c. 152, j 1(4),and we have no 12.0 tawf rap11 -alr`s
insurance reyuired.j r employees. LNo workers' 13.[°�Iher C�iirrsHeJ/
comp. insurance rcqui ed
•sea ..pphuaa the checks Eos AI must also sill wn the wo,ou Ixluw showing ihvu wurkms eunipunusiuo Iwliey it,iurrutiva
' I lomm,w nen who submit this alnJav it indica-ins they am Juina.11 work and awn hire uubWe caurxron must mhmit anew arGJavii indiunns.u.h.
-C',niracwr,that ahvck that boa must urtaahad an adduional sheer.howmjf aaa nano of Ihs subiontractuts and their wurken'cvanp,policy infurmannn
/tun an employer that is pro vidin,r ivurkers'cuurpenmrion incurunce fur ray etuployees. Below is the policy and job.Aire
infurnturiun.
Ir.,uraucc Company Name: r� f �./vT✓d/ .L as. . -- - -------'-
I+olicv a or Sclf-ins.^Lic�.yn: &JCL2/- J/S _=3J 61e
� �7 a BcS�� Expiration Date:
lliq
VJob S irc Address: R. �7�—,r� Cuy;stalaZlp: le r"t
.\-tach it copy of alae workers' cumpensatlen policy declaration page(showing the policy it bar and capitatiun date).
Fadwc to>ecurc coserage as required under Section 25:\of.%KA e. 152 can lead to the imposition of criminal penalties of 3
fnc tip to]1.5110.X1 anSur otic.-ear imprisonment, as well as ciul penalties in the form of STOP WORK ORDER and a fine
Of up to 5250.00 a Jay .against We violator. lie adva+cd that a copy of lhu statement may be fur%ardaJ to the Office of
Ins:,u•,a unt>til-',he UL\ :or ut,w aCs a,v sage ucriliaatiurn.
/du herrhy ccrrify under the pains mid perurlric% oflikerjary that the irtfunnurlon provided,above is true and correct.
.ZOO
711-rd "r
only. Ou nor avrire in d�ir area, tube cunrp/rrrd by airy or Iorvrt a/tic iu/. I
n: . PermitiLiccnse 4
urity (circlenae):
IIv.Jllt ! Cil).-Iona CIcrk J. L•'Icclrica) Inspcclor i, Plwobin4 In>pcctor
('nntacl l'cmml: .. _. Phone tl:
I '
Information and Instructions
\f.l�i.ii 11 u5ells Gi neral Laws iii Diller I?2 requires all cnlplo)crs to provide workers' compensation F)r their employees.
1'ur.u.mt to this aaurte, an emplolee is detincd as- .every pcison in the service of another under any contract of hire,
c xprees or Ilnphcd. oral or wrnten.-
\n elnployer is defined as"an Individual, partnership, association,corporation ar other legal entity, or any two or Inure
.'t the h,r"ou;g engaged it a joint cnlcrprlse, and including the !cgal representatives uta deceased employer.or the
receiver or trustee ul.m individual,panwmcrship,association or usher legal conty,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,can%trucuon or repair work on such dwelling house
or on the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. �%25C(6)also states that "every state or local licensing; agency shall withhold the issuance or
renewal urn license nr 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."
kdditionalfy. NIGL chapter 152, §25C(71 stades"Neither the commonwealth nor any of i6 political subdivisions ,hall
anter into any contract for the performance uf'puhlic work until acceptable evidence ul cunnpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
please fili 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 their cerlificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no cmployces 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
Ac idents for continuation of insurance coverage. Also be sure to sign and date the affidavil. The ag'lidavit should
he 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 questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town official -
Please he 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.
Plast be sure to fill in the penniulicense number which will be used as a reference number. In addition,an applicant
lilac must submit multiple pen applications in any given year,need only submit one affidavit indicating current
policy in(omation(if necessary) and under"Job Site Address'the applicant should write "all locations in (city ur
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 filled out each
)tier. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(1":. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he ,)I IICc til IilveStlgition> would line to thank ),)u 111 advitnec Dur your cooperation and Should)ilii Ila%c :uly questions,
pleasc du 1101 hesitate to give us a call.
1-he L)cparanenfi address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
oft8ce of Investlgedons
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
a:•.:,cd '0-05 www.mas3.gov/dna
CITY OF SALEM
:l
:t%. 4 l PUBLIC PROPRERTY
I
'�,.. DEPART'.MENT
U.\+III\i,. 11:11.1'r • SAI I\t, \I.\+i\I .. 1 . .1 t _
1'\S: 97N.'4=-')S4,�
Construction Debris Disposal Affidavit
(required lex all demolition and renovation work)
In accordance \vitb the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in if properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
7f f
(name of*hatter) . -
I he debris will be disposed ufin
(name of lacility) U
• J/ , A49j0,V 01-IF
tnddress ul'facility) n �/
signature of prnuit applicant
elate
1
0
Avg �
n {`
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
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: Derby Street
Address of Property: 97 Rear Hardy Street— Hooper Hathaway House
Name of Record Owner: House of the Seven Gables Settlement Assoc.
Description of Work Proposed:
Rebuild center chimney from the roof line. Save and reuse existing brick and supply matching old brick as
needed Use same lime mortar mixture as used in previous chimneys and in same thickness as existing. Install
new 41b lead flashing.
Dated: April 16, 2009 SALE 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.