14 CHESTNUT ST - BUILDING INSPECTION (2) I� The Commonwealth of Massachusetts **W9N**A&
Board of Building Regulations and Standards
IWII r� Massachusetts State Building Code, 780 CMR, T"edition
Building Permit Application To Construct, Repair Renovate Or Demolish a
One- or Ttro-Fam n r!ling
This Sec For Qtlicihl Use Only
Building Permit Numbee �/ at A lied:
Signature: - '"`✓ b
Building Commissioner/Inspeciwo uildings D
SECTI IN ATION
I.I Property Address: Assessors Map dt Parcel Numbers
li Ches>Lr„�� Sf. Y
1.Is Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(j.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal V On site disposal system ❑
Public Private❑ Check if es❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner`of Record- ►/���y n
Name(Print) k Address for Service:
�� Ili*-AIII?
Si FroposedWork':
re Telephone
CTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Existing Building❑ Owner-Occupied i� Repairs(s) hZ' Alleration(s) ❑ Addition ❑
Accessory Bldg.O Number of Units d Other ❑ Specify:
': e- o� >+ a Chun
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees:
4. .Mechanical (HVAC) S List:
5. .Mechanical (Fire S Total All Fees: S
Su resxion
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 4 t,,6 06 0 Paid in Full 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N4me of CSL-fielder List CSL Type(see below)
s
Address T Description
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature ,M Masonry Only
RC Rcsidcnnal Room Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.......... O 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.
-/y-e 9
n re of owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the airs and penalties of perjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/arics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
`lumber of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "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
.A 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: MclDlirg
Address of Property:
Name of Record Owner: Thomas & Katherine MuuaY
Description of Work Proposed:
Repoint chimney to replicate existing. No changes in color, material, design or outward appearance. Non-
applicable due to being in kind maintenance.
Dated: May 26 2009 SALE T L 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.
CITY OF $ALE.3I
PUBLIC PROPERTY
DEPARTMENT
Kl�••••�cv oluf
Wv0/ 130WA9W4GT MSnMT 9 SAt11KMAnACWSWM01970
TEL 97L73S-9S" •F.%X 976-740-990
HOMEOWNER LICENSE EXEMPTION
Please Pr(tat
Date 7-i 1- o f
Job Loeadon J# GSesfn Sl
Horne Owner Address s
Home Owner Telephone 9 yT- 71/4-9iJ1,
Present Mailing Address S'cins_
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not posses a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside. on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATLRE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SsU_E.`[, .LkSSACHL;SETTS
13U DLNG DEPARTMENT.
120 WASHINGTON STREET, Y's FLOOR
'a TEL (978) 74S•959S
FAx(9711) 740-9846
KI, F DR
Y ISCOLL
MAYOR D THosta ST.PtEmm
DIRECTOR OF PUBLIC PROPERTY/11VI DLNGCO-%L%BSSI0NER
Workers' Compensation Insurance AMdavit: guilders/Contractors/Electricians/Plumbers
applicant Information Please PrintLegibly
Name (Bus,ma 0r4anizmiom Indsvtdual): J61-yidAh Mt v /�� IyirrdV RSohYV tL�d ND/1
Address: f�D. Qox P�ur�f
City/State/Zip: Sir MA 42y72 Phone* ME 7H--Y//6
'%rre,(you an employer?Cheek the appropriate box: Type or project(required).
1.lYJ 1 am a employer with 3 4. ❑ I am a general contractor and 1
employees(full and/or part-time)." have hired the sub-contractors 6. ❑New construction
on
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet :
?• ❑ Remodeling
.hip and have no employees Then sub-contractors have a. ❑ Demolition
working for me in any capacity. workers'comp.insummm 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,f 1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers. IJ ❑OtheraQaboihl ({tl/slhea4
comp. insurance required.)
-Any applicant tNt checks 11011101 must 21Mr rill wt the section below shanties their workme'canopew"dtn policy informanat.
'I hmineuwrws who submit this anldsvir indicating they an doing all work stet then him otmide contncpn nttaa suhmii a now artldavit indicting such
T.mtmcun that cheek this ban muss anxhad an additional aheet showing taw rarest of the subs araetarn and their woken•comp,pdicy informtion.
I am an employer that Is providing workers'comprnmdan lnsuronee jar my employees Below/s the polley and fob slat
information. i77 U
Insurance Company Name: e- z/a1hLd
Policy M or Self-ins. Lit. N: 6,5- WEC, -.10 8Lvr9 Expiration Date: 03 0 6 Ile
lob Sire Address: /Y aCSkgtl- sic City/State/zip: SAlitn, Ml Oi7D
,tittack a copy of the workers'compensation policy declaration page(showing the policy number and expiration dab).
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be furwarcicd to the Office of
Invicenyratiurut of the DIA for insurance coverage verification.
/do hereby serfify un^de�r the pains and penitlt/es of perfury that the infbrmmlon provided above is true and"rreea
iWkial use a dy. Do not wrier in this area, to be a'volpleted by city or town offlc isd
City or fuwn: _- Nermit/LlcenseN__.
i
Issuing Aulhurtly (circle one): j
1. Iluard of Ileallh 2. RuildlnU Department J. Cily/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C„nlact Person: _ _—. -- Phone N•
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CHANGE IN INFORMATION PAGE
INSURER: TWIN CITY FIRE INSURANCE COMPANY
NCCI Company Number: 14974 AUDIT PERIOD: ANNUAL
POLICY EFFECTIVE DATE: 03/06/09 POLICY EXPIRATION DATE: 03/06/10
Policy Number: 65 WEC I08459 Endorsement Number: 01 HOUSING CODE: DX
Effective Date: 03/06/09 Effective hour is the same as stated in the Information Page of the policy.
M Named Insured and Address: BRENDAN MURRAY
0
PO BOX 8454
SALEM, MA 01971
N
0
O1 FEIN Number: 018642231 PRO RATA FACTOR: 1.000
d' PRODUCER NAME: USAA INSURANCE AGENCY INC/PHS PRODUCER CODE: 812846
o It is agreed that the policy is amended as follows:
ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING
N STATEMENT.
o THIS IS NOT A BILL.
0
o IN CONSIDERATION OF AN ADDITIONAL PREMIUM OF $1,300 IT IS AGREED THAT:
x
THIS ENDORSEMENT REFLECTS ADJUSTMENT IN PREMIUM BASIS DUE TO
RECENT AUDIT COMPLETED FOR THIS INSURED.
(A) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 5022 FOR INSD 01
ST 20 LOC 01
Countersigned by
Authorized Representative
Form WC 99 00 06 A (1) Printed in U.S.A. Page 1 (CONTINUED ON NEXT PAGE)
Process Date: 05/12/09 Policy Expiration Date: 03/06/10
ORIGINAL
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(rcyuircd li,r all demolition wid rcno%ation \vurk)
In accordance will the sixth edition of the Slate Building Code, 7S0 CAIR section 1 1 1.5
Dcbris, and the provisions ulAIGL c 40, S 54;
Building Permit At is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
I l I. S 150A.
The{debris will he Irmsportcd by:
Inamc ul haular
I lie debris
/will be disposed of in
' Inulnr u(13uluy)
t.ldJrc.. .d'I�clliwl
25-7411,
.ipnalwe d pi nnit .ygllldJn
IJId'