14 CHESTNUT ST - BUILDING INSPECTION Jtx The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7it'edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied: 0
Signature:
Building Comnlissionerl Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property dress, 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: i
-- --
�Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY
//OWNERSHIP'
[
2.1 wner'ofJE Record: /
KaY4,?/hP &Iyu'.¢)C �T' ��•erYker( Gl- .-ty.�. ��1.
Name t) � �-- Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Desc ,pjton of P oposed Work2
T" g fP.
v
SEC ION 4: ESTIMA I'c?D CONS'FRL'CTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ O 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 Cos[: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) A 773ra /V a �.
v q/M -f q.,eixe_ License Number Expimti. n Date
Name o' L-Hot erg / / List CSL Type(see below)
Q.9( t T e Description
A U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
g
nnatuurreeM Masonry
C ResidentiaOl Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Ap2liance Installation
r. I Residential Demolition
5.2,[p stered Ho pe 1rrovegle.tef Contractor(HIC) (1
7 /R Z .
HIC C maniName )IIC Registrant e �ClRegi tration Number
Z Awl—
j . r '
Ad
Expirati n Date
ature Teiephone
I 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
I oC-X. as Owner of the subject property hereby
authorize
V ^ tKu .er co to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature_N,Aner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Q- tj _ ,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.
� CI .e�ce
Print N O
✓ t
Signatur fOwnerorA horize Agent Date
Si ne / der the ains and enalties of perjury
NOTES:
I. An Owner who obtains a building permit to do hisrher 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Floors 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"
1
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
r a SMI-M, MA\%%' III it I n0197�
Ycl: 778.715.9395 • 1:%x 97x.N1'-'ss46
Workers' Cumpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
i )licant Information �t
Please Print Legibly
Velnl: kBu.uusit)rkanlr:ui.nVlndl>utuaD: _ ��� c--frYd
i
�lldl'os:
City,Stare,Zip-- e Phone ;/: ( 7� �� lit �
Are >mu an employer:'Check the appropriate box: - "Type of project(required): _ - .-_•
1 4. ❑ 1 ;un a general contractor and 1 G. New construction
I. l ant a employer with ❑
emggloyccs(full andor part-tinge).' have hired the sub-contracture 7. ❑ Remodeling
listed on the attached sheet. :
?.❑ 1 till or a sole proprietorpartner-
ship and have et (it s These sub-contractors have K. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 1). Building addition
l Kn workers' comp. insurance 5. ❑ We are a cei poration and its 10.❑ Electrical repairs or additions
I required.) OttSeers have exercised their
3. I :till n homeowner doing all work S exemption right of per MGL 11.0 Plumbing repairs or additions
❑ Pon P'
myself. tNo workers' Lump. c. 152, ¢1(4),and we have no 12.❑ Rlwf repairs
insurance required-] r employees. [No workers' 13.❑ Olher
comp. insurance required.]
77 .;gdaan rhm ahwks box 01 must alau lilt um the,ecllan Ixluw showing Their uurkui cumpen>utiufl pull y"Mille lium
'I lommlv,nen whu xdtmif Ihis affidavit indivang Ihnp am doing un work atua Ihcn hire outside cutumcmn must.uhmil a new arrdavil indiueng,ueh.
-fomrxtirn that shcuk the Dos mist atuched an iddilion4l..Ixel,hawing the nenic of fht subKonllaCtan and then tsurkun'cr,rnp,puhcy mfurmariun.
/ant lilt employer that it pruviditsk workers'cuwprottstion inauronce jar iffy eutployees. Below is the policy and job site
itlfUrlllUtllln.
I n,urance Company Valne: --- - - .--- - --------- !j
I'olicv g or Sclf-ins. Lic. n: -_5�.. �j . .. __ Expiruuon Date: '✓z ��L`
Job Site Address:
( C.v(QrGl�dl LN.__ U, c CnyrStutI!/Zlp:
Attach it copy of lilt workers' cumpcnsatiun policy declaration page (showing the policy number and expiration date).
Failure to secure toe-eruge as required under Section 25A ul'>IGL c. 152 can lead to the imposition of criminal penalties of a
tine up tm 51.5110.00 and/or one-year impris ninunt,as %%ell as civil penalucs in the loan of a.STOP WORK ORDER and a fine
Of kill it) 5250.00 a Jay againsl the violator. lic advised that'a copy of this stutcment may be l'urw arded to the 011ice of
Im.,m_auuns ul the DI,\ :or ug,urance ern erugc ,eriliwtun.
/do hereby lcrtijr under ily p,sitw uud pettaftlep 4perjory that the information provided aboveis true and correct.
O(liciul sue only. Do not write ill this urea, to be cu,up/eled by city or town aj/iria/.
(city or fnw•n: _.._ __ Permit/License 4.
Issuing Aullturily (circle one):
I. ll.,ard of llvalth 1. nuili ing Department .i. Cil)."Ibwu Clerk 4. Electrical lo;pector 5. Plumbing lucpccior
6. Other
Cuntaet l'cr>ma: .. __ Phone #:
Information and Instructions
massachusets Gcneral Laws chapter I i2 requires :III employers to provide workers' compensation for their employees.
Punu.mt to Lois ,tatuic. in em)afvrre is defined as"._every person in the service of another under any contract of hire,
c apreos or nnp(acd, oral or written.•'
An rrrrpfayer Is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Or the t;I(ctNing engaged in a joint enterprise, and including the Icgal representatives of a deceased eniplo)cr, or the
receiver or trustee of aii individual, paitncrnhip,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three .apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, cumtruction or repair work on such dwelling house
or on, he grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. §25C(6) 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 commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, ;%,IGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance_
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that upply to your situation and, if
necessary. supply sub-contractor(s)name(s), address(es)and phone mandaer(s) along with their certificates)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 stare to sign and dale the affidavit. The aff idavit should
he retuned 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 Depurtmenl 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 fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'Isisc be sure to fill in the pennit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple pennitAiceirse applications in any given year,need only submit one affidavit indicating current
policy infoimation(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 chat 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.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
t he I)I IiCc of 111velrl.ations %%ould line to thank )'ou in advance fur your cooperation and should you have :any questions,
please du not hesitate to give us a call.
The Dcpartncnt's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Olflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-7274900 ext 406 or 1-877-MASSAFE
- Fax p 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PRoPRERTY
DEPART',/IENT
J�..
i
I I ; v-g.'44. ) 'J73.'4= '1i4i.
Constrtletion Debris Disposal Affidavit
(rcyuired litr all denwlition :utd renovation "'k)
In accordance WIll the sixth edition of the Slate Building Code, 7SU CNIR scctiou I 1 1.5
DcbI is, and the prop isions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
ILLF
1 name of hauler)
1 he debris will be disposed
of in
(namr .,(lacihty
�dres. u1 lac;luvl
✓� , t_
N dilute 51 Ifi 111111 .ytpLcmn
Mall
• �o
v�
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 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: Thomas & Katherine Murray
Description of Work Proposed:
Replace wood decking and treads of side porch with Trex decking in same dark color. Paint risers to match
trim color.
Dated: June 19, 2008 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.
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 7a5-9895 EXT 311 FAX (978) 740-0.04
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Constriction ❑ 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 4t
Name of Record Owner: Katherine & Thomas Murray
Description of Work Proposed:
Repair/replace side porch to replicate existing. Raise railing height to meet code, posts to be proportional.
Risers to be one piece with overhang and molding. No other changes in color, material, design, location or
outward appearance.
Dated: Mav 8. 2008 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.