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B-17-855 - 0011 ANDOVER STREET - Building Permit The Commonwealth of Massachusetts ' i ld E 0 z QR Board of Building Regulations and Standards �a Massachusetts State Building Code,780 CMR `MUNICIPALITY W ' �n C� � USE Building Permit Application To Construct,Repair,Renovate Or Ddfhlo�i§g? —bRe>fed J53011 Ul One-'or Two-Family Dwelling ?,. This Section For 0ffictal.Use Only Bwldtn Permit Number g., . - I?qeApphed BuiIdmg Official(Pent Name) Signature Date P SECTION 1 SITE INFORMATION 1.1 Puoperty Address: 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes _ no Map Number Parcel Number ' 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided I —— + 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2 PROPERTY OWNERSHIP : 2.1 wner'of Record: r�i c k 0� Soil�'nr /y1�4 0!J . Name(Print) City,State,ZIP 114 Nkver- �-, -6 AVi . No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work2: C'`I` 'd� f�0- „ roo 1!!�: a 9 ` t SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials y 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ f. ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ '�/� Check No. Check Amount: Cash Amount: (DT tal Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Co struction Supervisor License(CSL) ©7 ),o3 ,1/3 aC)i.7 0Coti,vp r License Number Expiration Date Name of CSL Holder C J t S`A/v� s List CSL Type(see below) A Type Description No.and Streett I 11414 1 O/® 70 U Unrestricted(Buildings up to 35,000 cu.ft. ( R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding p C71 SF Solid Fuel Burning Appliances J3 !�r J/ I Insulation Te hone Email address D I Demolition 5.2 egisterre/d Home Improvement Contractor(HIC) 113 � 53 451651a011 / r�)N -TN C, HIC Registration Number Expiration Date HIC C pany Name or ItrR�egiOs toNa� ST No.and Str et `3 Email address sM-M"K� oYJ 0 City/Town,State,ZIP 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 I,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,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. n/ ( .v G° a Alva O f1°6 W Print thorized Agent's Name(Electrons(Signature) Date NOT . 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.maaLgov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor 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 cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" - m 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: ❑ 'Corstruction ❑ 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 District Address of Property: I I Andover Street Name of Record Owner:Richard Keon and Brent Thompson Description of Work Proposed: ■ In-kind replacement of existing 3-tab asphalt shingle roof in dark gray. NOTE: This approval is for 3-tab asphalt shingles ONLY. If architectural shingles are to be used, a new application must be submitted to the Historical Commission to request a Certificate of Appropriateness. There will be no changes in color, material, design, location or outward appearance. Non-applicable due to being in-kind replacement. Upon completion of above work,please notify Historical Commission staff as final sign-off is required to document compliance with this Certificate. Dated: _August 17, 2017 SALEM HISTORICAL COMMISSION By ^Ca 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. Once completed,please submit a photographs) of the final result(maximum of four-i.e. one photograph of each affected faVade). 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. • I