B-19-252 - 0002 BROAD STREET - Building Permit G� 2- Lt
The Commonwealth of Massachusetts
1: OR
,. Board of Building Regulations and Standards =_ > �+ -
Massachusetts State Building Code, 780 CMR + C �'
t USE
Building Permit Application To Construct,Repair,Renovate Or Dem �h4 � tP4vis1K4rcl11
One-or Two-Family Dwelling
This,Section For Official Use Only
l n Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
C� SECTION is SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la 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
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 Owner'of Record:
eh 5 eU�ytSG s1 �a�cy�-- okC- O L q 7
Name(Print) City,State,ZIP
t��_ S den ze br` wU)S �co !
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief De�scri � f P� :-ReA U � - P e.vt
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate77�eef is determined:
l�vv�2.Electrical $ ❑Standard City/Town Application Fee �,
OQ ❑Total Project Cost'(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:
L6-Total Project Cost: $ �L� QO ❑paid in Full ❑Outstanding Balance Due: .
K0 W/C. Do f-1 cow
SECTION 5: CONSTRUCTION SERVICES ~
5.1 Construction Supervisor License(CSL) �+S I D/a 7�p 6 —Zp—Zd
License Number Expiration Date
Name of CSL Holde_r
cc List CSL Type(see below)
Description
No.and Streef
Unrestricted(Buildings up to 35,000 cu.ft.
b02,n V&-5 t '' Restricted 1&2 Family [)welling
City/Town,State,ZIP M Masonry
(,` _ ___ RC RoofingCovering
WS Window and Siding
SF Solid Fuel Burning Appliances
7(f<�3 _223( I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I A 5r0 3
&9�(e Md,�s- 11Yl1 f =-Zg6oroLle�� HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Nai e
/I S'tlyan S� (fdd e LIP,od, ana rs
and Striet Email address
No.sa-r?L`e3 44�-
City/Town,City/Town,State,ZIP Tel hone
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...........O
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.
Print Owner's or Authofized Agent's Name(Electronic Signature) Date
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 can be found at
www.mgaLgov/oca Information on the Construction Supervisor License can be found at www.mass. ov/d s
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"
I
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:
❑ Construction ,❑ Moving
X Reconstruction ❑ Alteration
❑ Demolition V.
❑ painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or 'wolves 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. x
District•�LcIntyre '
Address of Property:2 Brad Stf
Name of Record Owner:Jennifer Stevenson&Adam Keach
Description of Work Proposed:
A Remove second floor window on the back of house and replace with clapboard
Non-applicable due to not being visible a public way.
Dated: February 20.2019 _ S M HISTORI t
COMMISSION ;
B
The homeowner has the option not to commence the work(unless i ela es to resol outstan
violation). All work commenced must be completed within one year from this date unless otherwise
indicated.
Once completed,please submit a photograph(s)of the Jlnal result(maximum of four-i.e. one
photograph of each af}ected fagade).
I
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.