22 CHESTNUT ST - BUILDING PERMIT APP (002) O�r7 a f%(/ Ud
The Commonwealth of Massachusetts
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Board of Building Regulations and Standards CITY M
(VJ Massachusetts State Building Code, 780 CMR SdMar
1 Revised Mar 2011
Building Permit Application To Construct,Repair,Renova r Demolish a
One-or Two-Family Dwelling
This Section For Official Us Only
Building Permit Number: Date Appl' d•
t t L
Building Official(Print Namet Sigra,ture00, Date
SECTION 1:SITE INFOR A ON -
l.l Pro Address: 1.2 Assess Map&Parcel Numbers
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l.la 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(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.C.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 ��0 ner of Recor
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Name(Print) City,State,ZIP
cyou w ST 4116'p4&V-7
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 9 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2.
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: I
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 (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression
Check No. Check Amount:• Cash Amount:
6.Total Project Cost: j ❑Paid in Full ❑Outstanding Balance Due:
C
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SECTION 5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL) l i `G
�/��D LJj��,,l✓.(G..�-p� License Number Expua on D e
Name of CSL Holder
List CSL Type(see below)
No.and Street Type ' Description
Q/ �7 U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
V1J4zx I Insulation
telephone Email addr—esi D Demolition
5.2 istered Ho re Im/prove nent Con etor(HIC)
C��/� HIC Registration Number Ex 'ration pate
=dSt,,,eSt
rHTC Regi _ Nay a I/1 M E tai addresse,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 buildiA permit application.
Print Owner's Name(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
containe in this application i t and accurate to the best of my knowledge and understanding.
riot Owner's or Au[h ent's Name ectronic Signature) CAate
- NOTES: ,-
L 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.a 142A.Other important information on the HIC Program can be found at
www.mass.covi'oca Information on the Construction Supervisor License can be found at wwlv.mass.eovidns
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"may be substituted for"Total Project Cost"
' � ONIII
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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 detennined that the proposed:
❑ Construction ❑ Moving
O 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:22 Clicsiout Street
Name of Record Owner:Nina Cohen
Description of Work Proposed:
Rebuild chimney frrom rooJline. T ork inchies new lead flashing. All evorlc tvill be in-kind.
A Certificate of'Appropriateness will be obtained from the Historical Coninussion to install a new chumic.3: cap.
Dated: June 13 2013 SALW,H[STORICALCOMMISSION
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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 1S 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.