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1 CHESTNUT ST - BUILDING INSPECTION (3) r t The Commonwealth of Massachusetts ,1 k .1 Board of Building Regulations and Standards CITY t� Massachusetts State Building Code, 780 CMR, Th edition OF SALEM Revised Jomary Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or Two-Family Dwelling This Section For Official Use Only \ Building Permit Number• Date Applied: Signature: '��ls✓i —`a-o.� / txJ// (C� Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address.. 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?yes Z no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(Il) 1.4 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply:(M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone?Public Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 2a a ,erA h c���t, i - isfi Name(Print) Address for Service: `l # S� 1P 3 Signature telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(chfck all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) K Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Propos d Work': f1 n L >► e e 1QA c X, 6 aeI n SECTION J:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S 1114 Qe 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costs(Item 6)x multiplier - x 3. Plumbing S 2. Other Fees: S a. Mechanical (fIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S �_ Check No. Check Amount: Cash Amount: 6.Total Project Cost: S Q d 0Paid in Full ❑Outstanding Balance Due: 1 f SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 0 A � �t ✓1/1 �� J/S Licensee Number Expiration Dute XAdd ' -I Io1Jer),L List CSI-Type(see below) U 0 f Description U Unrestricted u to 35,000 Cu. Ft. R Restricted 1&2 FamilyDwelling CM :':. Maso OnlO -� [ RC. .., Residential Rootin Coverin WS' Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5 Replered Horn Improv ent Cootr t ( )f 1 Ro Risey► e� crnrs `�fe5 FITC Cum any Name or HI ' gutrant ems— RegtstrmionJNumber AJJres zi/ i� G� !7� ! L / ��✓ / µ Expiration Date Sistfulult Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 152.4 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L L44 �/_t'�L as Owner of the subject property hereby authorize to act on my behalf, in all matters relative ett�too{work auth rized by this building permit application. s/ - 72 — / d Si atu re of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 4 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�A11 Q t �Q A Print Name �I-ze-/tel Signature w er orA h e AS At Dale Si ed under the Wins d Walters of 'u 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 no have access to the arbitration i 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 I IO.RS,respectively. 2 When substantial work is planned,provide the ml'ormation below: Total Iloors area(Sq. Ft.) (including garage, finished basementlattics,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" 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 LeBel Description of Work Proposed: Repair of halfround window on East side (facing Summer St. and repair/replace surrounding siding to replicate existing. Replace cedar siding on North side (facing Chestnut St.) to replicate existing. No changes in color, material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: April 1, 2010 SAL TCIA17COMMISSION By: The homeowner has the option not to commence the work (unless it relates to resolving an outs g violation). All work commenced must be completed within one year from this date unless othe "'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. CITY OF S.U.Ea`t9 NLxss koi 'SEM SUMKILVG DEP-mmiENT 120 W.\iHCVGTON STREET. )m FtOOR TM. (978) 143.9595 F.ut(971) 74498" KlN®EA"y DRISCOLL 71WNAS5T.PM"A MAYOR DIRECTOR O►PL eLiC pIWPERTY/SLILDLNG COMOSSIO.NER 1Vurkers' Compensstioa Insurance AMclavir guilders/ConirsetorWElea'trlelsnslPlumbers knnllrant Infortnatlots Please Print L IM Varna Itlusmearorymran/Ia��n111twkv.dsal) Al)5re f)l In it� eb olaa Address: 13 UJI n pSO i'^ Kr/ City/State/ZiliL Morns Are you tarpmyw!Chock the spprepeieto boas Type of projeet(requlr"IN ... j. airs a employer with -,? 4. Q 1 ars a gnaal ceeb'aetor and 1 b. Q Now construction employees(Rall and/or part-time).• have hired the msbconuwu rs 2.Q I am a soN prspriattr or paw listed at the attached sheet = 7. 0 it ling .hip and have rat omployes Than sub•cwtteamn have s. Q Demolition wockin e ice as wortars'cotnp insurance P g fat my capacity. S. Q We ars•c 9. Q DuiWing additive [No workers'comp insurance ��and is 10.0 Electrical repairs or additions r quird.l often have esuccl ed their 3.❑ 1 am s homeowner doing all wort Milo of exernprion per MOL 11.Q Plumbing repairs or additional myself.(No workers'comp c. 132.#1(4),ad we have no 12.Q Roof repsin insurance required.l r employees.INo worker' I7.❑Other comp insurance n quird.) '.1ny apsY.ae iti saarba ea/I rr else t10 w rhe crus baM Ie.iy thdr esaate' Pub i.im.stlaa. 's l.e.arweew who erbata ads ated"iOdkWft they am dei I ell eark cad Ar hie stern&ceararstra seal eelereb a now atlhbr undim ieg seed T,wnaww.Ir.hwk 1W bee must aertwd p rterierl der.M%iq am Ira of tM•A"Mrsi in was their ware"t ew7.pwtay,incarnation. /eve ace erplsyer char tr peev!/hrP wwters•eawpwCswrMw/warrewajw err)/taq/syes dNw 4/Ae pNleT tuN/a5 s(dr injorrar/aa G VAR t A l tJA4 & �J In.urrncaCompany.Vamo: /�,, �Q Policy e w Self•ins. Lia.e: b 1A/C t9�{P ` w Expiration Due: —�q� fub Sire Addnsa: P �" I� City/SlaWZip: :l� nl �V/e4 -- --- attach atopy of ibe workers'compnuaden-poft declaralln pep(stewing tlw polley number and asplredinS dab)6 - -- Failure to sewn coverage as required under Section 25A of NGL a. 132 can lead to the imposition oferiminel penalties ora rine up to S 1,300.00 and/or one-year imprisomMr&,an wed as civil penalties is the farm of a STOP WORK ORDER and a lite .•r up to S250.004 day against the violator. Ifs advi*A that s curry of this statamant maybe furwurded to the Olyrce of it,vc.t,gations ol'Ute DIA ror insurance coverage veriduatioUL , /,/a hereby eertify Aw rhe and peneh/w o/perjury,that the informative prariddrel4aw is nor end eweeeg Pen aTzf © � - i O/j&rie/ust an/yv Oo not write in thin mel.to 6e.urnp/ird by cityW feline 11/dried City or ruwn: PermivI.Itense Inwng.\uthwrty(circle onH: I. Ilwrd u(Ilraltk t. Rudding Department h. City/town Clerk 1. Electrical Impeclor S. Plumbing Impactor 6. Other Phone e: I CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I'.II: Mlfl ' Mly.'II \I .•„N I.Cu'AH11\I..•4•t)INkrT 0).\I1 fl. it -4 I.•.1'r . ,. fel:4 471.4.1i'N P\r:Hl/•NS't 1/A Construction Debris Disposal Affldavit (required tur all demolition and renovation work) In accurda n:e 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 ft 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 I 11. S 130A. The debris will be transported by: Inome of hauter) The debris will be disposed or in plana ul aci Ily • A, puldms ul'I'acdityt V .I�natur I lxrmit applicant slate