2 ANDOVER ST - BPA-09-659 RESHINGLE FA The Commonwealth of Massachusetts Town of
ZJ Board of Building Regulations and Standards a
;e Massachusetts State Building Code, 780 CMR, 7" edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kmomw vm
One-or Ttco-Family Dwelling
This Secti or tci Use Only
Building Permit Number: �I D t A lied:
Signature:
Building Commissioner/Insoctor of B ilding Date
SECTIO E INFORMATION
1.1 Property Address: S� 1.2 Assessors Map& Parcel Numbers
--��1�
Ma Number Parcel Number
I.I a Is this an accepted street?yes_ no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed-Use Lot Area(sq it) 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.4u,134) 1.1 Flood Zone information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if esO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Tf Rec + �nyek
AdAdress for Service:
Name(Print)
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Cl I Accessory Bldg.O 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building Permit Fee: $ Indicate how fee is determined:
L Building S 000
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
r
ressionCheck No. Check Amount: Cash Amount:
otal Project Cost: S / 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
� P -lp
�C-a/ ICY P -License Number E,-;,-,ii4 Datc
Npmc of C -Hykler� n List CSL Type(sec below) U
Address------- Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Si nature (q M I Nlasonry Only
RC Residential Roofing Covering
Telephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Im rovement Contractor(HIC) I
�t C.�/la P� I iP ��r rnrtf / tnc('i thm i !tea :
HIC,Sompany Name or IC Registrant Name Regtstran NumNum e�—
a �/ &/zzloy -
7u1 — �Q —Qf Expiralion Date
S:gnalUre Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 25C(6)) ICI
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
5 to W't t A L as Owner of the subject property hereby
authorize M t c A ri N to act on my behalf,in all matters
relative to work auth d b h t g p rtnit application.
7l2.slava `?
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, .'T li ci•,h s 'S TA,v r,A t- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nam _
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of riu
NOTES:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
r
. o
Salem Hhto ical 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: McIntire
Address of Property: 2 Andover Street
Name of Record Owner: Thomas & i uciana Stantial
Description of Work Proposed:
Replace clapboards on the front of the house to replicate existing. Replace trim where needed on house to
replicate existing. Replacement ofporch gutter to replicate existing. No changes in color, material, design,
location or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: March 25, 2009 SALEM;I 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.