13 CHESTNUT ST - BUILDING INSPECTION j
SECTION 5. CONS+TRUCTIO}Y SERVICES
51 Constructton Su/ p&visor License(CSL) 6 /�
License umb uati Date
N e of CSL Holder• 'il.j[, ; �`•
%3`kDY�NE I-ANi- List CSL Type(see below)
o.and Street Type -- :
D Unrestricted(Buildings up to 55,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town,Statt,ZIP Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
; 3(-M4 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
:TO (,
XbWt✓:n C( ��rmhttACIQ.25 CRegi lion Number ira on Date
HIC Company Name or HIC Regisumt Name
No. d Street Email address
& Ira 979-sN-lhe9
Ci /Town State ZIP Tel hone
SECTION 6:WORIMR31'COMPENSAIIO 1 INSURANCE AFFIDAVIT(NLGJL 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 ..........E! No...........❑
SECTIO14 7a:OWNER AUTHORIZAMN TO BE CO LETEI)VAIEN
OWNER'S AG ANT OR CONTRACTOR APP1,10 F'4R B ING 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 7h-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 Authorized Agent's Name(Electronic Signature) ate
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
mvw.mass.govloca Information on the Construction Supervisor License can be found at www.mass.eov/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 of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
� . : :K
Salem Histofical Commission
120 WASHiNGTON STREET, SALEM, MASSACHUSE TS.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:
i
❑ 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 District
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Address of Property: 13 Chestnut Street
t
Name of Record Owner: Nicholas Kiefer M.D. and Jennifer Rousseau Kiefer
Description of Work Proposed:
i
Repair/rebuild two chimneys (one a center of house and one at rear abutting driveway) with in-kind
materials.
Replace existing rubber roof and 3-tab asphalt shingles with in-kind materials.
No changes in color, material, design,location or outward appearance. Non-applicable due to being in-
kind replacement.
Dated: March 29. 2016 SALEM HISTORICAL COMMISSION
�A t _{-�. � _
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.
Once completed,please.submit a photograph(s) of the final result (maximum of four-i.e. one photograph of
each affected fagnde).
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. g
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