14 CHESTNUT ST - BUILDING INSPECTION (3) The Commionwralth of Massachusitis nt
t Board of Building Regulations and Standards AII'Nll'll' \I.II l
Massachusetts State Building Code. 780 UNIR. 7°i edition I 'SI`.
.� n I
Building: Permit Application Tip CosuuCL Repair. RenuN:ue Or OCloolish a R, i iwd.h,mw,
One- or To,i) y Drrel[ilig 100S
It "This Section Fo,Official Use Only
Building Permit lnher: r S Date Applied: ----.-- ---_
Signatue: _
II p Cimunuswned In ciu r at B.uldi'g 1)tic �
LV SL�Cc-"IA 1: SITE INFOR11:\'1'[ON
i
1.1 Property Address: ) / ( 1.2 :Assessors Map K Parcel Numbers
/ � ( t m, hibsvf -f . I
1.la Is this an accepted sneer'.' yes_ )C no Matti Number P:ucel Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I_ut Area(sq ti) Frontage(it)
1.5 Building Setbacks (f )
j Front Yard Side Yards Rear Y:ud
! Rcquned Provided Required Pro%tded Required Pn: idcJ
1.6 Water Supply: 6v1.G.L c.10. §S1) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside yes Lung" Municipal ❑ On site disposal ,�,icm ❑
Public ❑ Private ❑ Check it yes❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco d: (/j • ,/Y/L f/ �L
rt Pi714-eP (1((Z 0(u�rAl/ l 7 C
Name I PrinO 4 dress for Service:
4Ye:;r'-- 7qci4 - c 65� -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(cheek all that apply)
on struction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ .Alterution(s) ❑ Additwn ❑
New C
Demolition ❑ I Accessory Bldg. ❑ I Number of Units I Other ❑ Specity:
Brief Description of Proposed Work-: `
py ti' r7l2 _e'9i✓ LLl!!-cC bGt /F/LvJ
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials' Official Use Only
I. Building S 3 1. Building Permit Fee: Ii 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: S
J. Mechanical (HVAC) `S List:
I
5. Mechanical (Fire S
Sut ressitm) Total :AII Fees: S
Check No. Check :Amount: (Lohnon:---
j b. Colal Project Cost: y 2f �- 0 Paid in Full 0 Ou(standin„ Balance Due:
SECTION 5: CONSTRUCTION SERVICF,S
5A Licensed Construction Supervisor(CSI.) r
Licrnse :\umber la
Name otCSL-JI ill der �� ���
List CSL, l'cpc see bclowl
T' I Do"ri now
W r.
i C l nreuncleJ lu p to 35.1110 Cu- Fl.r
Resuictcd 1&2 F.muk D%,olhne
Sig uurc .VI A1Luonrc Unly
r RC Ite'lJeililal Itoullnc ('o�cnne,
Telephone AA'S Ite>idenuul ACuidoii .inJ Siding _
Sh Rc+idomiJ Solid fuel fiurnme \ i it i.incc In.i.illdu u
D 12rsiJmival Dcuwlnin
5.2 R ' i tered !l2ue npro omen 'ontract (111C)
Q V G1C f �'-
IiIC Com iany "y jp or FlIC Rsei runt N n 7 �, 12eeuu'auun Nuumher
Addr
y L %� ((yg-7 ��—� 7 Fcpirafion Datc
Si wture Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed Lind submitted with this application. F:ulurc to provide
this affidavit will result in the denial Lit 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
1. as Owner of the subject property hereby
authorize ✓ !4 QtAE' to act on my behalf. in all mattersrelative to work authorized by this building permit application.
Signature of Owner Date
SECTION 711h: OWNEW OR AUTHORIZED AGENT DECLARATION
r-�
(, (J' , 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 Lind
behalf.
`��
Print Name
Signature of veer or Authorized , gent Date
(Signed ill r the gins and enahics
NOTES:
I. An Owner who obtains a building permit to do his/her own %koik, or an owner who hires all unicilisteied contractor
(not registered in the Home Improvement Contractor (HIC) Pnigrair ), will not have access to the arbitrmion
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Piogiam and
Construction Supervisor Licensing (CSL) can be t0tind in 730 CMR Regulations 110.R6 Lind 110.RS, respectively.
'- When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.I !including garage. finished hasemenUatics. decks ,n porch)
Gross living area tSq. Ft.) Habitable room count _
Number of fireplaces Number of hedruoms —_
Number of bathrooms Number m half/haths
Type of heaunt!System_ Number of decks/ porches -- —
Type of.cooling system Unclosed _ _Upcn _
3. '"Total Project .Square Footage" may be substituted for 'Total Project Coot'
CITY OF SALEM
PUBLIC PROPRERTY
,. DEPARTMENT
J`S•icET 0 S.\I.
iFl i')i95 t°\.'(: ')7d'?iv9di6
Construction Debris Disposal Affidavit
(required fur all demolition wid renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Dcbris, and the provisions of Nv1GL c 40, S 54;
Building Permit p - _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly Licensed waste disposal facility as define by .,v1GL c
t I I. S 150A.
The debris will be transported by:
--- warne of hauler)
I'hc ,kbris ww ill be (!i>)oscd of in
v�
I�,.+re�i ilc�lrty)
4 —.
/.n
CITY OF SALEM
0::6)
PUBLIC PROPRERTY
DEPARTMENT
.•.Oil is I � hN lit :�,,
.. \LU,yi I_': U'\,III?:�;1� ��'11!<II-,I • �.0 iV, \L\.t.\i ll; .P l !,:1`/'�
Workers' Compensation Insurance AftidaNit: Builders/Contractors/Electricians/Plumbers
A D tlicant Information Please Print Le ibl
/�f
Nml I I e t Iiu.arcs tlreamcu I,in,In otds,d ll is C
�
Address: /fi ti 15;X
,(J
City,State:'Zip: IQ t0-4Ch9Jr ��10 O Phone 4:
\re you an eniployer'1 Check the appropriate box: '!'ype of project (required):
1.� :tin a employer de ith1. ❑ I am a general contractor and I 6 ❑ New construction
employees (full and%or p'art-ti me).* ha%e hired the sub-contractors
7. ❑ Remodeling
n
2.❑ I :ti a sole proprietor or partner- listed on the attached sheet.
,hip and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
otticers have exercised their 10.0 Electrical repairs or additions
required.[ Plumbin re airs or additions
J.❑ I am m a hoeowner doing all work right of exemption per MGL I I.❑ g p 1
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' LIED] Other
comp. insurance required.]
•:\ny applicant that checks box01 muat also till out the section below showing their workers'compensuoun policy infumtatiUn.
t I Iomcuwncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:C,olractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I din an rnrployer that ids providing workers'courpen.sation insurance for my employees. Below is the policy and job site
inf artuation.
Insurance Company Nana:
Policy #or Solt=ins. Lie. #:
q ✓ 7 / Expiration Date: ®�
17
obSite ,Address: ��e����✓ c City/State/7_ip: � � t( "
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
line up to S 1.�0O.Oo and/or one-year imprisonment. as well as civil penalties in the timn of a STOP WORK ORDER and a tine
of tip to 5250MO a d;ry against the violator. Be advised that a copy of flits statement may be tbrwarded to the Office of
Imc>tivalions of the DIA for insurance coverage verification.
l doa hereby certifi' under the pains and penalties of perjury that the injirnnatiotr provided ubore is true and correct
�icn.murc:
Date:
tl f Jicial use only. Du not write in this area, to be completed by city or town officiaL
('ilr or Ilion: --_--
Issuing Authority (circle one):
I. Board of Health 2. Building Department }. CitN fown Clerk J. Electrical inspector ;. 1'lunihing inspector
0. Other --- ----
Contact Person:______.— _-- Phone #:___ --
Information and Instructions
\Ias<aChuseus General 1_1%vs chapter I " rCyurCS all rntplo%CIS to prop i.le %%orkcrs' conytensanon for their employees.
I'll]suant o this >ninte. all rmpluree is dehncd as " C%cn person in tale Sea ice of;unnher under any contract of (tire,
c\press or implied. oral or tsrittcn."
An engrint'er is ,lelined as ":in indi%ideal• partncr.hip, association. corporation or other legal Cunt%. or any tow or more
,,I the foregoing engaged in ajoint cntcrprise. and including the lc.al rrpresentati\cs of a deceased employer. or the
rccri�cr or trustee of an individual. panncrship• association or outer Irgal entity, employing employees. I lowever the
,�•�nee of a dtkelline house having not more than tree apartments and who rcSides therein, or the occupant of the
.ht Clline house of another who employs persons to Jo m;uintrnanee. Construction or repair work on such dwelling house
of on the groun.ls or building appuriCnunt thereto shall not because otsuch employ nuent be JCentcd to be an Cntplo}'er."
SI(il.. chapter I i?, �250h) 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 cor unonsvealth for anv
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, .,%IGL Chapter 152, S250 7) states "\'either the commonwealth nor any of its political subdivisions Shall
enter into any contract for the pertortnance of public %%ork until acceptable evidence of Compliance with the insurance
requirements of this chapter hove been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
nCCCSsary, Supply sub-contractor(s) name(s), address(es) and phone nuniber(s) along with their certificate(s) 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 he 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 he sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must Submit multiple pemtitvlicense applications in any given year, need only submit one affidavit indicating current
policy inforniation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." 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.c, a dog license or permit to burn leaves ctc.) said person is NOT required to complete this atftdavit.
The Ot)ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
pICOSC Jo not 11CSItate to give us a call.
the I)Cparuncnt's address, telephone and fix number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 l 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itc%isCJ -,s-us Fax # 617-727-7749
www.mass.gov/dia
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: 14 C b stn t St.
Name of Record Owner: Katherine & Thomas Murray
Description of Work Proposed:
Reconstruct fan window on front of house to replicate existing. Repainting of house as needed. No changes in
color, material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: April 2, 2008 SAI,F.M HIS -
MISSION
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.
r�.�y-U� ,, ' .
. , .,. ..