14 CHESTNUT ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�§ Massachusetts State Building Code, 780 CMR SALRevised EMlar 20/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For O cial Use Only
Building Permit Number: ate Applied:
Building Official(Print Name) SignaturY Date
SECTION 1:SITE INFORMATIO
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
)!{ C-4est,uf S't.
1.1a Is this an accepted street?yes . ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy ft) Frontage(R)
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:
�o,nes +,Ln J/serhe l''l,.rraJ SQ./Gn a
Name(Print) Cily,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: CrAZPO/Q
Brief Description of Proposed Work':
ze °
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
t. Building $ �J ..0 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:
5. Mechanical (Fire $
Suppression) 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 Supervisor License(CSL)
License Number Expiration Date
Name ofCSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 FamilyDwelling
Cityll'own,State.ZIPM Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
City/Town, State,ZIP Telephone
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
1,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.
7—JAI-
Print Owne s lame(Electronic Signature) Date
SECTION 7b: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) Dale
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 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. ov oca Information on the Construction Supervisor License can be found at +-�i w.nutss.«ovrilns
�. 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"
CITY OF S.UY.bt
PUBLIC PROPERTY
DEPARTNLENT
u.ouus+r oasmL
Vwvae I b WMMCIM ftW•&USK VAYAO&MM OIrG
HOMEOWNER LICLNSE EXIMMOIN
Ptew prime
Date 7- )4- )1
Job Loeadae 14 C'JtiP sfi,flf S' .
Home Owner Address (,sa he-)
Honw0warTelepbsas 97f` 7H-N--!9ii4
Presed Mailing Address i* Ch e shl u i 8i-. �,Wv„� MA o/I n
The current exemption of"Homeowner"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hie who.does not possese a Ucau 4 provided that this owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons)who owns a pa cel oflaod on which Walls resides or intends to mefdsr on
which there h6 or is intended to bst a one or two dmily dwelling, attached or detached
structures accessory to such use andlor firm squetura A person who constructs more
than one home in a two year period shag not be considered a homeowner. Such
'?>omeowner"shall submit to the Building Official,on a Ions 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 bylaws and regulations.
The undersigned "homeowner"catifiea that he/she understands the City of Salem
Building Department minimum impaction procedures and requirements and that he/she
Mill comply with said procedures and requirements.
HOMEOWNERS SIGNATURE An
.APPROVAL OF BUILDING NSPECfOR
See other side for state code
L'
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 619-5685 FAX (978)740-0404
CERTIFICATE OF APPROPRIATENESS
♦
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 will be appropriate to the preservation of said Historic District, as per the requirements 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 Chestnut Street
Name of Record Owner: Tom and Kate Murray
Description of Work Proposed:
Construction ofgazebo in location noted on plan of land Option for design to be either Amish County Gazebos
Pagoda or Majestic.in 10'octagonal, painted white to match house trim. Roof'shingles to be architectural in
either Rustic Cedar or Weathered Wood.
Dated: July 11, 2011 SALEM HISTAO�RIICCAL OMMISSIO
By: Vitel
C� /
The homeowner has the option not to commence the work (unless tes 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.
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