1 CHESTNUT ST - BUILDING INSPECTION (4) � . CK � '-��6 2S � ��
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� Board of�uilJing Regulations anJ Standards pLEM
� a�/ hlassachusetts Smte Building Code, �so cNiR 2016 D�,;.��,ti,l�zqpl -�
�'' Building Permit Application To Construct, Repair, Renovate Or Demolish a
�" One-or Tivo-Fmnily D�ve(ling
I This Sectton For 0�cia1 Use Onl '
� Duilding Permit Numbee ` Date Appliedt
` R 15 1
ry � Oui�ding OtTicial(Print Name). . _ -� -:-��,Signatura•. �.. .�.- . - D��
�.. SECTIONI S(TEINFOB��IAT(OIW ..: '
� L 1 Property Address: 1.1'Assesson binp 8c Parcel Numtren
i CwE�`*�wrC- �T'
I.I a Is this an acce ted street?yes no M1fap Nwnber Parcel Number
1.3 'Loning Informatton: I.J Praperty Dimensions:
"Luning Dislrict Proposed Ux � Lol Area(sy ft) � �mnlage(Il)
I.5 8uilJingSetbncks(ft)
Front Yard Sida Yards Reor Yanl
Reyuin:d ProvideJ Required P'oviJed Required Provi�ed
t.6lVnter Supply:(M.G.L c.J0,§Sd) 1.7 Flood Zone Informatloo: 1.8 Sewage Disposal System:
Zune: Oulside Flaod ZoneT Munici d O On siee dis sol s slem ❑
Public❑ Private O — Check if ne0 P P0 Y
SEC'f[ONZ: PROPERTYO�VNERSHIP!'
2.t Owner�ofRecord:
�— � 1�I1�! �R�-�
�hme(Print) City.Smte,ZIP
\ �t.w� � �,t�-5�8�-+�t se��CR.�'� .c�
Nu.anJ Si+cel Telnphane Emai�Addrtss
SECT[ON J: DESCRIPT[ON OF PROPOSED WORK=(check all thu!apply) .
New Consln�ction O Existing Building O Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ r�ddilion O
Demolitiun O Accessory BIJg.O Numberof Units Other pecify: O�-Ct�
�rief Description of Proposed Work': -co.i� Pi�vn - �F- 2� �`�`� �F'
SECTIOY�:ESTIDIATED CONSTRUCT[ON COSTS
���i�� Estimated Costs: Oftldrl Use Only
Labur and�laterials)
I. �uil�ing � I. Building Permit Fee:5 Indicate how fee is determineJ:
�StanJard Cityll'own Application Fee
2.Electrical � p Total Projeet Cost�((tem 6)!c multiplier r
3. Plumbing S 2. OtherFees: $
d.�Iccluviical (NVAC) S List:
5.�\lechanical (Firz S fotal All Fets:S
Su rcssiun) '
� Check No._Chzck Amowit: Cash Atnount:
G.Tofal 1'roject Cost: � '�Z�' ❑p;�id in Full ❑OutstanJing Dal:mce Due:
/ /���'���
����a��.-I�� I a-020�''� �
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Gs. pg3tto3
y
License Number Expiration Date
Name ofCSL [folder
ListCSL'fype (see below)
Type - - Description
No. and Street -
U I Unrestricted(Buildings up to 35,000 co. It.
&n.
R Restricted 1&2 Family Dwelling
Cityfrown, State, ZIP
M Naso
RC Roofina Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Q kencws .,ly7 ` •� �
1 Insulation
D Demolition
Telephone Email address
5.2 Registered Home Improvement Contractor (HIC)
)HIC
�� �S3Jaddress
Registration Numn DateHIC
Company Name r HIC Registrant Nameacn> t1. Aar.,1No.
and Street
EmCi
/Town State ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L: ,Workers
Compensation Insurance affidavit must be completed and submitted with this applicatividethis
affidavit will result in the denial of the Isivanc of the building permit.
Signed Atfldavit Attached? Yes .......... No ........... O
SECTION 79.OWNER AUTHORIZATION: TO BE.COMPLETEDWH.,
OWNEIVS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize ai^-4 P4C'
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Print 0 ner s atr nft 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorizcd Agent's Name (Electronic Signature) Date
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 ne have access to the arbitration
program or guaranty fund under tM.G.L. c. 142A. Other important information on the HIC Program can be found at
www mass cov'oca Information on the Construction Supervisor License can be found at www.ntass.eov'dns
2. When substantial work is planned, provide the information below:
'fotai floor 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 h:dt%baths
Type of heating system Number of decks/ porches
fypeofcooling system Enclose) Open
3. , rotal Project Square Footage may be ;ubstitutcd lur "'total Project Cost"
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
❑
Reconstruction
❑
Demolition
❑
Signage
❑
Moving
❑
Alteration
✓
Painting
✓
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 District
Address of Property: 1 Chestnut Street
Name of Record Owner: Richard and Janice LeRel
Description of Work Proposed:
Repaint east side of house (Summer Street) to match existing colors: Benjamin Moore white (n•im),
Essex Green (shutters) and custom gray (bod)).
Repair damaged /missing section oj'shingled rool'with matching 3 -tub asphalt shingles in grab.
There will be no changes in color, material, design, location or ounvard appearance. Non -applicable
due to being in-kind replacement.
Dated: October 24, 2016
SALEM HISTORICAL COMMISSION
By:
t
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.
Once completed, please submit a photograph(.v) of the final result (maximum of four - i.e. one photograph of
each affected fa(-ade).
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate pennits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
Cl'lYCrAPSALE9 MASSAaMT.
&»LMuMW
�MWays7ttar,9'°Fxm
HL 70..
AAxO99957004
►arc« �. �. :i ...• i i TI .•
Construction Debris Dispose/Adovit
(required forali demolition and renovation work)
In accordanoe Wk h d* sbcdh edition of do State &dd ft * ode, 780 Serdon 111.5 Debriq
and the pro*j= of MGL oto, S54; PermitiM is lswedwith the
h:ono ion that the debris Mufti from this work deff be disposed of in a prgpe* iicemed
waste depm* facility as defined by MGL c 111, S 15k
The debris will be transported by:
(name of hauler)
The debris will be disposed of In:
(name of facilfty)
Date
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:
Address: 0"2 CnJ <� IR�t.t�C�l �Y Zgo
City/State/Zip: aiX_jEtr\ t7jAC OAIrQ—eVO Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
1.0I am a employer with I!S- employees (full and/
5. ❑ Retail
or part-time).*
6. ❑Restaurant/Bar/EatingEstablishment
2. ❑ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box N I must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #I .
I ani an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: 1aAc12T($.fL I\IS
Insurer's Address: &0 LMt IJ.e k te, QC>
City/State/Zip:
Policy # or Self -ins. Lic. # b rb GO l.i13'o'oZ31.t �� ��{ Expiration Date: fS/G� !
Attach 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 lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, f dWyl, the pains ands of perjury that the information provided above is true and correct.
Oficial use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
www
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fenn Revised 02-23-15
®i Massachusetts Department of Public Safety
�� _✓'� Board of Building Regulations and Standards
License: CS -093403
Construction Supervisor ,
SEAN OCONNOR
26 CHESTNUT ST
SALEM MA 01970 -
j-JZ7, CA Expiration:
Commissioner 1 213 112 01 7
UorwuoaKrnp/// n/rC�l /
Ogee of Consumer Affairs & Business Re 11pr rride(/r
OME IMPROVEMENT CO B°talion
egistration: CONTRACTOR
123553
xPtration: 3/6/2017 TYPe:
DBA
Preserve Painting
Sean O'Connor
203 WASHINGTON ST. #256
SALEM, MA 01970 —9:L
�—
Uaderseeretary