0002 - 0004 CHESTNUT STREET - BPA-14-1380 The Commonwealth of Massachusetts
WBoard of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR 110FCTI�NA RevisedMa 011
Building Permit Application To Construct,Repair,Renovate Or Demolis a 1 A & 2r�
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 1,,
Building Official(Print Name) Signature 'K�-
Date /
SECTION 1:SITE INFORMATION
1.1 Property Addres _ 1.2 Assessors Map&Parcel Numbers
Lla Is thistan an ccepted strreeeat??byes no Map Number - Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:,
--AAye�
Name(Printtt))�/ _City,Statue,ZIPS
No.and Street Tele— phone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $$
4.Mechanical (HVAC) $ List: r
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervis r License(CSL) c
fo dv'
Cry k Expiration Date
Name of CSL older
CSL Il,A\ A �� Lis[CSL Type(see below)
No.andS Street "v "" "'d Type Description
> W\ ��S h v(?a? U Unrest cted Buildin s u to 35,000 cu.ft.
J-� r t R Restricted 1&2 Famil Dwellin
Crty/Town,State,ZIP M Maso
�OGf � �J RC Roofin Coverin
WS Window and Sidin
,,�- SF Solid Fuel Burning Appliances
?( eYi`tMGI�� �1 I Insulation
Telephone Email address D I Demolition
5.2 Re rstered Home I rov�et-m-ent Contractor(HIC)
t> e 9� ` (w� HIC Re air ion Number E ira on Date
inc Com any ame or HIC egistrant Name
No.���lo��e
'7 Email address
— Wycs S MA
Ci /Town,State,ZIP el hone
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 7a: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:OWNER'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 Atithorized 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.eowoca 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.) (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 heating system Number ofdecks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
p � 1111
CITY OF SiU EMI1 ANSSACHLSETTS
t u t BUILDING DEP.ART\IE.\T
120 WASHLNGTON STREET, 3"'FLOOR
T EL (978) 745-9595
Rsix(978) 740-9846
KI\BERL F_Y DRISCOLL
"`.,LAYOR I11onL�s ST.PIaaJtr;
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\RIISSIONER
Workers" Compensation Insurance Affidavit: Buil(lers/Contractors/Electrlcians/Plumbers
Applicant Information Please Print [ e ihly
Name (Husineco Org.tniration Individual):
Address:
City/State/Zip: _!�> YUIY4J�i, Phone! :_56e��Xj'l ' q g
Arc nu un employer?Check the appropriate box: Type of project(required):
I.( I am a employer with_'� - 4• Q I un a general contractor and i
employees(full and/or part•time).• have hind the sub-contractors 6. ❑New cunnwction
( 2.❑ lama sole proprietor or partner- listed on the attached sheet. t 7. 0 Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9. 0 Building addition
(No workers'comp. insurance 5. 0 We are a corporation mid its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I ant a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152, §1(4),and we have no 12.E--T[Zoof repairs
insurance required.) t employees. (No workers' 13.[] Other
cutup. insurance required.)
'Any upplicall dwt checks bur si mwt atsu rill rut n+e section bctuw showing their weners'coniNnaaiun pu4y inlitrtnntlun.
' Ltmauwiwn lt,ho wbmit this affidavit indicating they arc doing all work and then hire uutsido contractors mint suhmit a new airdavit indioling such.
('....radon that chuck this bus mwt auachoe an aaditiurul.hul showing the none of the subwemneWn and iheir wurken'comp.pulley infumistion.
I atit an turployer shut ly providing Ivorkers'cumpntratlati in.rurauce for my enrplo}tees. Daia;v is fbe policy and Job site
in/orntulinn.
Insurance Company Name: _._.._..__
Policy is or Self-iiu. Lic. q: __....— Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaratlan page(simwing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ot'\IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 and/or mu-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this stalement may be lunvarded to the Officd of
In vest igul ions tit',he 0 1 A for insurance coverage vcri ficatiun. -
/do hereby certify under the pains and penalties of perjury that the infonnuttan provided abuva Ls True and t-orreet
i'i,,fwlllrc Data:
Phunc �
(7f/icia!we ants. Ou nor rvrite in this area,tube camplefed by city ur ratvn n/Jiriut
CitvnrTnVil: _._ Permit/l.IcenscN__.._____,
1'suing Authority (circle one):
f. lioard of I[callh 2. Duiiding DcparUncnt .l. Cityifnan Clerk -1. I-Nectrical lnspcclur 5. Plnnthing Inspecror
ft. Odtcr
t Contact l'cruro° Phoov :t:_ ..
QTY OF SALEM, MASSAC RJSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,3" FLOOR
TEL.(978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNBSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
Z4Q ate..,. S�ie�
(name of hauler)
The debris will be disposed of in:
96-el� \9 . 9.
(name of facility)
(addr s of facility)
Signature of applicant
Date