40 BROAD ST - BUILDING PERMIT APP r J
ZN, The Commonwealth of M achusetts
�" qE Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
00o Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appli
Building Official(Print Name) igna a Date
SECTION 1:SITE INFORMATIO
1.1 Property Address: 1.2 Assessors Map Parcel Numbers
40 Broad Street_ 37764 25:254
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Residential R2 Single family dwelling 6870sf
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 X Private❑ Zone: No Outside Flood Zone?Check if yes0 Municipal X On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
John W. Sumner Salem MA 01970
Name(Print) City,State,ZIP
40 Broad Street 978-7444822 sumnerjw99@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied X Repairs(s) X I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ .Specify:
Brief Description of Proposed Work': Rebuilding back porch. Plan to keep the existing foot print and overhead roof
the same. Needs repairs to Flooring beams and stairs.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 0
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5.Mechanical (Fire $ 0
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
A
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City Fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF 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 .......... ❑ No...........❑
SECTION 79: 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cont ' this applic n is true and accurate to the best of my knowledge and understanding.
Prin er's or An ized 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 6670 sf (including garage,finished basementiattics.decks or porch)
Gross living area(sq.ft.) 1560 sf Habitable room count 7
Number of fireplaces 1 Number of bedrooms a
Number of bathrooms 1 Number of half/baths NIA
Type of heating system GasrFHA Number of decks/porches 1
Type of cooling system_NIA Enclosed Open_x
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
' gONaIT�
3 53
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
O 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: 40 Broad Street
Name of Record Owner: John W. Sumner
Description of Work Proposed:
Firing back porch: replacing rotting boards, stair treads and handrails. All work is in-kind.
Dated: May 13, 2013 SALEM HISTORICAL 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.