20 CHESTNUT ST - BUILDING PERMIT APP (002) W The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Gh Massachusetts State Building Code,780 CMR SALEM
Revised Mar Z011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied
Building Official(Print Name) Si ature Date
SECTION 1:SITE
INtOPAMMON-
1.1 Properly Ad ress:lax 1.2 Assessors Map&Parcel Numbers
a0 ?s c-ef Sty
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
a.
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 OWNERSFIIT"
2.1 Owner'of Record:
"'I`LYiG S ..s r Sr1lPo"1 -- �l�Tz
Name(Print) City,State,ZIP '
ao �P s�.tu -S W-
No.and Street elephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Others Specify: man
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 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 WAC) $ List: 1-,Owc, 6
5.Mechanical (Fire $
Su ression Total All Fees: $
ns Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 7 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
8P,2 /L 6-e q Lf License Number Expiration Data
Name of CSL Holder u
List CSL Type(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
( ✓'r / R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
n'�
SF Solid Fuel Burning Appliances
Zli (�`/139 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I6`?p'?g
M "rht>- ,p>f-0-17,10te" 7� HIC Registration Number EEKpiratiori
HIC C mpany&ame or HIC Regiftrant Name
V 0- -�gcn Rk-sK
No. c.and S et Email address
7;1M, � 019�/ �1�5`t'�`r��
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 APP-LIJES,FOR BUILDING PERMIT yr I,as Owner of the subject to hereby authorize le � L-emct.
to act on my behalf, in ers rel live to work authorized by this building permit application.
Print Owner's N lectronic Si amm) ate
ON 7b: OWNERr OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest trader 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.
_/-��e,//a
Print Owner's or Authorized Age ame(Electronic Signature) Date
NOTES:
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"maybe substituted for"Total Project Cost"
cor orr�Q'
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,Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 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:
CJ Construction ❑ Moving
�j 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: 20 Chestnut Street
Name of Record Owner: Craig Smith
Description of Work Proposed:
Rebuild front chimney (closest to Chestnut Street)from the roof line to replicate existing. Brick to match in
color, dimensions and design. Mortar to match in color, thickness and texture. No changes in color, material,
design, location or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: December 10, 2012 T 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.