1 CHESTNUT ST - BUILDING INSPECTION (2) The Commonwcalth of Massachuscits Town of
1 Board of Budding Regulations and Standards
Missachuscns Stan Budding Code. 780 CMR. 1'"ediuon Budding Dept
VVV Building Permit Application To Construct, Repair. Renovate Or Demolish a
One- or, Tiru warh-Divrff ng AMOS
This Secuo ,For Officia Use O
Bwldins;Permit Numbe . A lied:
Signature:
Budding Commissioner/I to of Budden Datt
SECTION 1:S TE NFORMATION
I Prort Add ass: 1.2 Assessors Map& Parcel Numbers
,�.. ., g fi
1.I a Is this an acc ted stree . yes no
Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Alan( R) Frontage(R)
IS Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Requind IProv.dcd Required Provided '
1.6 Water Supply:(M.G.L c.40.134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check ifiniso
SECTION 2: PROPERTY OWNERSHIP'
3.1 O cert f Recoed: J/''�
r1s+triii I�nt�-- Addnu for�ervicr. !-
9�4 59 �S�
Siputure telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied D RePairs(0181Alterations) Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Works: f7 L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Budding f � U I. Building Permit fee: f Indicate how fee n determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)s multiplier
) Plumbing f 2. Other Fees: f
i. Mechanical IHVAC) f
List: '
i Mechanical (Fire S Total All Fees: S
Su ression
Check Vo. _Check Amount: Cash Amount:_
is Total Project Cost S v ❑ Paid., Full O Outstanding Balance Due
�ff
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Comir cdon Shu"per isov (CSL► F� ,- G _ /a
r'Gi¢� 1fp Liccnse Number Eit iratwn Duar
N.yoe of 1.-SL. I lder Li.r CSL Type J cc h luw) U
A T Description
U I Unrestncted u io 13.000 Cu. Ft.
RRestricted IA2 FamilyDwelling
Signal r o `, �y N .Na only
c�' j RC Residential Rooftn Covering
Telephone w5 i Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
S. R#10bte)ZIred Hom Improvem at ontn or IC) l.L� ' 3 z Q
Hl C Company Name IC R� iraw N Registration Number
Add (% P �v Jr
Expiration Dale
S4natitire vTclephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 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 AlMdavit Attached' Yea......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
S�ECII
DI T] 0ON 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
t� o
1, (�JKJII�/ I —, J its el ,as Owner or Authorized Agent hereby declare
that the stateme ut and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
PrintN /J� �(h-o y
Sig o Owner Authorized Agent Date
Si under the 'm andpenalties of pli
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 gg 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 110.R1, respectively.
2. When substantial work is planned,provide the information below:
Total floors arca(Sec. FU (including garage.finished basementlarlics,decks or porch)
Gross living area ISq. Ft.) Habitable room count
.Number of firepli Number of bedrooms
.Number of bathrooms Number of half baths
Type of hearing system Number of deckv porches
rypeofcoolmgaystem Encbo,ed Open
1 "Total Pro)ect Square Footage"may he .uhvmuted for 'Total Protect Co.%C
Board of Building Regnbtfo and$tandarda I
Consbucdon Buperviaor Lkxme
LlerfrlM: CB 95459
a 10 Td 23213 I
I� GARY P MORRIS R 'n -
} 13.WINDSOR
ve
BEVERLY,MA 01915 " ' commissioner
I
Ll
Boakl of uildinuouaind Standards
NOME IMPROVEMENT CONTRACTOR
y+,
Repis ,p • 133293
Expirstlon__ 4/2011 TrB 283292
rLIabGIIY COMM
MORRISON REMODEINGAt+tEPAIR
GARY MORRISOftI'€ F '
13 WINDSOR
1 .' {'. rtrator
4. BEVERLY, Admini
MA 019 $ "-�
i
�_--..�..-__-. ._- . .""`TM""e'.�.'r�-...n.-•.....fes——a�__.�.�
CITY OF SALEM
31 PUBLIC PROPRERTY
DEPARTMENT
110 V AQ 1lN(.;hN Sj KErT 6 %Ms:.0
'frl:1)7H-'4-i-9;95 Fss:978J40-1t846
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
1I1. S 150A.
The debris
{will b,(e�transported by:
tname of hauler)
The debris will be disposed of in
4-
(name of acl ny) .
(uddrcss of tacthtyl
signature of I wt applicant
T- 0
(late
CITY OF SUEM. %Lkss kai SETTS
3VaMLNG DEPARTNIEINT
I'_0 WASHINGTON STREET, )aa FLOOR
TEL (978) 745-9595
FAx(978) 740.9836
K1,.,jBE1U FEY DRISCOLL THOeW ST.PizRis
MAYO)t
DIRECTOR OF PL eLIC PROPERTY/il'[LDLVG C0S01I5510V EIL
Workers' Compensation Insurance AMdavit: guilders/ContractorslElectrlcisns/Plumbers
Analicant Information n^ n Please Print Legibly
Name (ousin� OrWmtatioivindav,dual): ,AI Qg ow Runes e4VI P-,
Address: nme
City/Statrizip: d\eD(H Phone a: D S
Are you as employer?Cheek the appropriate boa: Type of project(requlretn:
I. m a cmploya with_ e• ❑ I am s general contractor and 1
employees(full and/or part-time).• have hired the subcontractors 6. C]New construction
2.❑ 1 am a sok proprietor or partner- listed on the attached sheet: ?- 0 Remodeling
ship and have no cmployea These sub-contractors have s. ❑ Demolition
working for me in an capacity. workers'comp.inwnaoe.
oink g Y9. Duiklin addition
I No workers'comp insurance S. C3 we are a corporation and its ❑ i
required.) officers have exercised their 10.0 Electrical repairs or additions
J. 1 am a homeowner doing all work right of exemption per MGL I I-C]Plumbing repairs or additions
❑ ti
myself.[No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance requited.)t employees.(No workers' IJ.❑Otho
comp insurance required.]
•Any applie=d thin shacks has Of mum Am fig was the soclim balm showing their workers,catttOwt polrey inftannm aaa
'I hmmtavne,who submit this affidavit indicting they am daing all wads and than him mAside comancaon mum"limit a trw amdevil indicating suet
{,mhm Tara AM cheek this ban mum aawhd an sldihimal aline.howina tin tmtan of the oh eman sw,my tMk wwkaa'comp.policy infumoam.
I am an simp/oyei thaw b praviding workers'compenradon Insurance for try emplayer% Below is flit pel/cy ofrd fol slay
information.
Insurance Company Name:
Policy Mur Self-ins. Lie.p: varz oo O+ 0O Expiration Data::('�J j�
Job Sire Address: G Q City/SmtriZip:_i.l�t – ---=�i
,%each a copy of the workers'compensation policy declaration page(showing the policy,number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lad to the imposition of criminal penalties of s
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form Ufa STOP WORK ORDER and a tiny
.)fup to 5250.00 r day against the violator. Ila advised that a copy of this statement may be furwurded to the 01Yce of
I avestillwiuns of ilia DIA for insurance coverage vcritication.
l do hereby errtif oder th F At penalties o/perlary that the infornradow provided a ve i trues and insurer
Q 1
Phone,i: 0
n/Jicia!use only. no nor writ.in this arra,to be rarwpleted by city or town nJ/h-hiL
City arfuwn: _ . PcrmiUl.IccnseM__.
ksuing.%uthority (circle une): — -
I. Iloard of Ilealth t. Ruilding Department J. City/town Clerk !. Electrical Inspector S. Plumbing Inspector
6. Olher
luntacl Pcnon: - ._. Phones-
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: McIntire
Address of Property: _1 Chestnut Street
Name of Record Owner: - Dr- Richard i eRel
Description of Work Proposed:
Replace 60 of rotted siding with new cedar and repaint to replicate existing. No changes in color, material,
design or outward appearance. Non-applicable due to being in kind maintenance.
Dated: October 13, 2009 SALEM H O 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.