B-19-1022 - 0032 BROAD STREET - Building Permit n
The Commonwealth of Massachusetts
Board of Building Regulations and Standards ^ - FOR
` MUNICIPALITY
�
Massachusetts State Building Code,780 C1v�REGTIONAL SER V4CES USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
I
One-or Two-Family Dwelling 1019 SEP 1.3
This Section For Official Use Only
I lr Q Building Permit Number: Date Applied:
Bwrdingfticial .rint ame)' Signatur
Dateq
SECTION 1:SITE INFORNYATION
1.1 Property 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
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'ofAr�ecord:
D A ^ G3
Name(Print) City,State,ZIP
qXa
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) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials Y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: 6
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
Iq
�. 4
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) - /C(F4�
DA-4� p $t — . License Number Expiration Date
Name of CSL Holder
,�p�,-�� ,. •r( List CSL Type(see below) y
-� }� D�y►�7 1��
No.a treet Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
l ( R Restricted 1&2 Famil Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
� ` 1 Solid Fuel Burning Appliances[��/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
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 ...........0-' No...........13
S a:OW AUTHORIZATION TO BE COMPLETED WHEN
WNER'S AGENT O CONTRACTOR APPLIES
,FOR
'BUILDING PERMIT
I,as Owner o bject property ereby authorize akb�
to act on my alf,in a s relative to work authorized by this building permit lipplication.
Print O am Electronic Si Date
CTION 7b:O ERt OR AUTHORIZED AGENT DECLARATION
By entering myLnaelow,I her y attest under the pains and penalties of perjury that all of the information
contained in thition i e and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dpss
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"
F �
QTY OF SALE4 MASSAMUSE M
BUIIbWG DEPARTMENT
120 WASMNGTONSTREET,310AWR
i TEL.(978)745-9595
j RIMMBERLEYDRISCULL FAX(978)740-9846
MAYOR
HOMDIRECTOR OFPUBLICPRO EM/BUILDING GOI►IlvIISSIONER
i
Construction Debris Disposal
Affidavit
(required for all demolition & renovation wor
k)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL 00,S54;Building Permit#
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
k4C—�C-1
(name of hauler)
The debris will be disposed-of in: ���
(name of facility)
(address of facility)
Signature o a plica
(today's da )
I
CITY OF SMY-2NI, 2NL-kss.,kCHUSETTS
BUILDLL'G DEPARTINIL iT
120 WASHINGTON STREET,r FLOOR
TEL (978) 745-9595
FAX(978)740-9846
KI�tBERT Y DRISCOLL
NLAYOR Tliomm ST.PlEm
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CON,51ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Applicant Information r lease Print Legibly,
Name(BusintssiOrganization/Individual):_ C ,� 2�
Address: L �N
City/State/Zip: f�#�-t'(�E� — Phone #:__2 9 �2
Are an employer?Check the appropriate box:
Type of project(required);
I tJ 1 am a employer with . 4. 111 am a general contractor and!
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance,
[No workers'comp. insurance 5. ❑ We are a corporation and its 9. Building addition
required.) officers have exercised their 10 O Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LC]roof
bing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.® repairs
insurance required.)t employes.[No workers'
comp. insurance required.] 13.❑Other
Any appiwarit tlutt checks box 81 must also fill uut the section below showing their workers'compmtuiun policy information.119mwowners who submit this affidavit indicating they arc doing all worst and then hire outside indicating such.
= t tors that cheek Ibis box must anachod an additional shoot showing the name of the suit-e con trnetio must submit o new altidavi!ontnrcwrs and their workers'comp,policy information.
Cunrx
ION an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company dame:
Policy d or Scif--ins.Lie.fJ:___ 8 Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage quired un r Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 a or one-year imp sonment,as well as civil penalties in the form of a STOP WORK ORDER and a Erne
of up to S250.00 a d y against the viol or. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the IA for insur ce coverage verification.
1 do hereby cert/jy and gins and pena/ties of perjury that the informatlon provided a ove l true and correct
t it Date: 2j
P a #
O
fficiale only. Do not write in this area to be completed by city or town o�eiaL
wn' Permit/License#
thority(circle one):
Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
rson: __ _ Phone#:
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
✓ 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: 32Broad Street
Name of Record Owner: David Pabich
Description of Work Proposed:
■ Replace existing 3-tab asphalt shingle roof with new 3-tab shingles in gray color. 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 repair.
Upon completion of above work,please notify Historical Commission staff as final sign-off is required
to document compliance with this Certificate and approved plans.
Dated: July 16, 2019 SALEM HISTORICAL COMMISSION
By: �- Pew.
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.