8 CHESTNUT ST - BUILDING INSPECTION 1
What is the current use of the Building?
Material of Building? If dwelling. how many units?�— '
WiU the Building Conform to Law?
Asbestos?
Archited's Name
Address and Phone
Mechanic's Name
Address and Phone / r4 a �
Contraction supervisors License#
O7 / 1 Z_HIC Reglstration# D
Estimated Cost t Permit Fee Calc Won
Permit Fee Estimated Cost X$7/$1000 Residential
Estimated Cost X$`I1J$1000 ComrnerciaL _--
An Additional 35.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the abov to
specifications. signed under penalty of perjury X -
Date b ��
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EI'I'y-OF giALhiV
PUBLIC PROPERTY
DEPARTNiENT
...oval 130 WASW1v TM S[IEIaT•
`•'yK.UAttA.UU:SETIs 01970
141974745.9S"9 FAM 976-74COW
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: r s ,, s Building;
Property Address- - --..--
e-5 mac- S
Property is located in a; Conservation Ares YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK.IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated Si
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
grief Description of Proposed Work:
e,GCi <Gs2
_
-----Mail Permit to: oo//
CITY OF SALEM
PUBLIC PROPRERTY
am- DEPARTMENT
XIM111 a1F.Y URMOLL
M. AY(* Ir.\nAsw.NC rote SrarxT 4 SA1EM,MAssA(:ia. errs 0197:
'rrla 978-743.9595 •FAX:9M744C,9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.Applicant Information Please Print Leeibly
.tame tduvness/OrganizatioNlndividual)/� xf,
Address: ��/ e17Icct-,Go L✓ ;.¢t,t_
City/smre/Zip: r���� /y/>zSS Phone #: 8�2/
\re you mployer? Check the appropriate box* Type of project(required):
1. am a employer with V--- 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employe"(full and/or part-tine).• have hired the sub-cuntractors
2.El am a sole proprietor or partner- listed on the attached sheet. : �• ❑ Remodeling
ship and have no employtxa These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
f No workers'comp. insurance 5. ❑ We are a corporation and its
required,) officers have exercistxl their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers 13.0 Other
comp. insurance required.I
.
Any ap plicaw tltel chucks bos e1 moat also till out the waian below chowiug their worktre'cumpunuaiwt policy infurm:uiwa
' lloma wrtera who submit Chia afRdavil indicating Choy are Being all work and then hie outside eonttapors mug sulvniC a new amdavil indi"iny,utuh.
:Cotem cwa Chia check this box must anaclad m addititmal Aces thawing the nmae of the Attt coruraelon and their worken'comp.policy information.
lam an employer that fs providing workers'compensadon lnsorancejor my employees. Below is the polity and job site
in ormation. / 1
Ituurance Company Name: �t'Ir'fr<rt. __ f//�/c-i 7a/`�'ca< o.
Policy 4 or SclGins. Lie. ri: (,/� ' �9SS0-2 2._ _ Expiration Date:
lob Site Address: City/Slate/Zip:
Attach a copy or the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a
li ne up to S 1,500.00 and/or one-year imprisonment,as well us civil penalli"in the form of a STOP WORK ORDER and a fine
of up to 5230.00 a Jay against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Inveangatiotls of the DIA for insurance coverage verification.
/da hereby certijy too er the pains nd alt' uj erjary that the/njarinatlon provided above is true .nd correct
1i �aatnre: D' t r
Ph,nicm
OJJrc/uf use wdr. Do not write lit this area, to be campleted by city or town of) ehot
City or 'rown: _ Fermit/I.1cense ft__,_ _
Issuing Aunliurily (circle one):
1. Board of health 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cunlacl Person: _ Phonc p:
CITY OF SALEM
PUBLIC PROPRERTY
_ DEPARTMENT -
>t„,+ t1cw.wau::a`SMUT4S�try.af.,.cu::u ni::apt
TFJ:v7174545" •F.VL OMAC-9s4f.
Construction Debris Dtsposa[ Affidavit
(required for all demolition am renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cb1R section I11.5
Debris, and the provisions of M. GL c 40, S 54;
Building Permit N _ . _ 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 M. GL e
111.S 150A.
The debris will be transported by:
(tta+ae ut tout
The debris will be disposed of in
Wa u of iaddrty)-
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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: R Chestnut St
Name of Record Owner: William 4choene
Description of Work Proposed:
Repair/replace rear lower level black/charcoal gray asphalt 3-tab roof to replicate existing. No changes in
color, material, design or outward appearance. Non-applicable due to being in kind maitenance/replacement.
Dated: October 29, 2007 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.