16 BENTLEY ST - BPA-10-810 REPLACE WINDOW SILLS & TRIM 1 The Commonwealth of Massachusetts
J t� Board of Building Regulations and Standards CITY
I !y ) Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
wwwss�� Revised Jurrnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. ?oaY
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Ins toro'Buildings Date
SECTION I:SITE INFORMATION
Lt Property A s` 1.2 Assessors Map& Parcel Number
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information ON�d 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Rryuired 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) O I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
�_ Wecj,S N/^604)IL4/ /Z! A6
'z- .4AI Do Wne N
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Q Q "o I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S
0 Paid in Full ❑Outstanding Balance Due:
l
SreaG 4rA4 PC— ,SECTION 5: CONSTRUCTION SERVICES
5.1 censed C (CSL) P,67 ZO&e J /fit { ZOG z
I.icense Number F Espimlion Date
N;unr offt-IIuIJer List C'SL Type(see below)
s>.2�eGre�e�4L
r�oc. I Description
U (lnrestricrcd u w35,000 Cu. Ft.
R Restricted Ik2 Famil Dwellin
Signature Q M Mason Onl
RC Residential Rarfin Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Rumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or IIIC Registrant Name Registration Number
Address Expiration Date -
I
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t �pc/O
1 � ,aR iDEe '@-Wpmy&&N e rod
as Owner of a subject property hereby
authorize�P7Z � ��% to act on my behalf, in all matters
rel rk authorized by this building permit application.
-Si am Date
re of Owner
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
/ ,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. ZS I�OlC�
Signature of Owner or Authorized Agent Dad
(Signed under the pains and pcnalticsi ofPerjury)
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
O
Salem Historical
o cal Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission
Ordinance, application is hereby made for issuance of a Certificate of Non-Applicability for:
❑ Construction ❑ Moving K Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
as described below.
C2��f �! �{LsTo��G
C, District: � Original Building Construction Date, if known:
Address of Property: /SO
Name of Record Owner(s): G
l�Ati'(J S1'iF�✓�Jk�O L!�'V !/v<r O E�
Description of Work Proposed:
I �E/�t1 cG /2o i TJ��✓ l 2�� OQ/ �'�aCG�s :,
/�ChL�Gt !N !<ZAI
Signature of Owner: P!i� �C �Cij sp el. #: ?J� <616 5
Mailing address: ��T� City: Stat�yqZip: �/�7
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: 1"32-1 34 Derby Street
Name of Record Owner: Derby Bentley Condo Assoc., Peter Talbot President
Description of Work Proposed:
i
Replace rotten trim to replicate existing. No changes in color, material, design, location or outward
appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: May 12. 2010 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.