28 CHESTNUT ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards al'E
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demoldf li 28 Q C� 4;
One-or Two-Family Dwelling
� This Se@�on F9r O� :ike
Building Park Nua , _, Date rick]:
13iri1ding OfSc�1(1'�1'�e) Signaave
i SECTION1:SITE.I�1 WORMA71O1N"
1.1 xSY 11;perly dress: 1.2 Assessors Map&Parcel Numbers
c�FFe s71Jor' 57
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq f) Frontage r11)
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 es❑
SECITON2: PR08'ih:R3'YO�VI+IEILSIIIFPt
2.1 Owyerr of Record. -
A/yai HAad �/ d1NaP/ �l/1Q°rn.On/
Name(Print) ��— City,State,ZIP
4;f
Telephone Email Address
SECTION Sx DESCRIPTION:OF PROPOSED WORK'(ohe&aN tbat apply)
❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
tion o Proposed World:
ke�`a_s of ra. , �C FT CiJT rr 190 s✓7- Qos,,,,y ✓
SECTION 4:ESTMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Fox;;&Fee.$ Indleate how fee is determinedk Standard cttr -
/Town Application
2.Electrical $ O Total Prpject Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees
4.Mechanical (HVAC) $ �'
5.Mechanical (Fire $ Total All Fees:$
S ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ d $ 3 ❑Paid in pull ❑Outstanding Balance Due:
'3 12 M IN t L c:q -n ct)r.3T'R .
SKMOiN s: C N SMuCTIQAI SERVICES
5.1 Construction Supervisor License(CSL) L9 C(3 9!l f 2
WW License Number/ irati Date
C "Name o CSL',Holder .
List CSL Type(see below)
No.and Street
((��
U Unrestricted 'din to 35.000 cu.ft
PW GLS �?A Z Restricted M2 Family Dwe
City/rown,State,ZIP M I masonry
RC Roofing Covering
WS Window and Siding
�r I Solid Fuel Burning Appliances
I Insulation
Tel hoe Email address D Demolition
5.2 Registered Home Improvement Contractor(MC)
HIC Registration Number Expiration Date
HIC Company Name or" t Name
,n
No.and Street Email address
Ci /Town State ZIP Tel hone
SECTION&WORKERS'CGAHTMATTON MIMMANCE:APFIDAVMT(d►3."c.152.$?5"*)
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 ..........O No...........❑
7a:OWNER AUTIFORMAUM TO BE COWLETED E1V
9WNER'S ACANI ,•J 9R 1 E�t7tlt,If_. ��T# IG
1,as Owner of the subject property,hereby authorize r 4,14 -T' C I/ r hAs 8 i✓ c4
to act on my behalf,in all tiers relative to work authorized by this building permit application.
AW Yok� ( w7-/, -2A //6
Print Owner's Name(ElecuRmc Signature) - Date
SECTION lb-OWNER'OR AUTHiOMED 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) Date
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
Mvw.mass.gov.!oca Information on the Construction Supervisor License can be found at wµlvmass. ov/d s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
:
SECTION 9. PROPERTY OWNER AUTHORIZATION
i Name and Adu ress of Pro erty Owner
Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mad address
If applicable,the property owner hereby authorizes
4m ice -- 3-4ar-¢deLT �I,e-
N.vne Street Address City/Town State - Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.it.of enclosed space and or not under Construction Control then check here 0 and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
lAck 3 y FC
Name(RegistaL Tele� a e-mail address Registration Number
5-�ASQ pll. e1
Street Address - City/Town State Zip Discipline xpv: ton Date
10.2 General Contractor
��Q �5 �✓�uR-e
Company Name
A4� (s-&-,4 ) CS
Name/of Person R ponsible fur orunction License No. and Type if Applicable
7/9VLt o As /412P tm—
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANC1:AFFIDAVIT M.G.L.c.152.S 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) TotalConstruction Cost(from Item 6)
RTot
$ Building Permit Fee=Total Construction Cost x_(Insert here
l $ appropriate municipal factor)_$
g $
cal (HVAC) g Note:Mininmm fee=$ (contact municipality)
Mechanical Other - $ Enclose check payable to
st $
(contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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 any knowledge and understanding.
Plese print and sin name Title Telephone No. Date
Street Address City/Town n State Zip p
Municipal Inspector to fill out this section upon application approval•
Name Dae
The Commonwealth of Massachusetts
W
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
_(This Section For Official Use Only)
BuildingPermit Number: Date A li
e PP Building Official:
SECTION 1:LOCATION(Please indicate Block itf and Lot N for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable) _
SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ I Repair)L I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
ChangeofUse ❑ lChangeofOccupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit'pplication? Yes ❑ No ja
Is an Independent Structural Engineering Peer Review required? Yes ❑ No il0
Bri Rescription of Proposed Work:
/mac!! A� tr( ° C�,9T M✓ �✓ 6L� 41 op �a
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s); Proposed Use Group(s):
SECTION 4f BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sad. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-t❑ F2❑ H: Hi h Hazard H-t❑. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ i Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ I U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ Ill ❑ I►A ❑ fill ❑ I11A ❑ Hill ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Hood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ indicate municipal❑ required❑or trench or specify:
Private❑ or indenlify, Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \I.\t ti t ru_C}mum w�� .:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): "type of Construction: . Occupant Load per Flour:
Uoes the building contain an Sprinkler System?: _ Special Stipulations: ____
r
CITY OF SALEA4 MASSACHLBETP
BLKDMDEFAJMMW
120 wa9m4MMSVJffr,30ADCR
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Fil7c 7d0.9846
H>]�ERIFYD6Eti�dI,
MAYOR Z�ra�rssST.P�Re
DJUCXMCFPUukpyxrmy/Buuw4GamnamcNm
Construction Debris Disposes/Affidavit
(required forall demolition and,.renovation work)
in accordance with the sbdh edition of the State Building Code, 780 CMR, Secdon 111.5 Debris,
and the provisions of MGL c4O,S 54; Building Permit B is►slued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 156A
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
E.'
//eo
1 I
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
Vj Reconstruction ❑ Alteration
❑ Demolition 0 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: _28 Chestnut St
Name of Record Owner: Anne Harris & Andy Lippman
Description of Work Proposed:
Remove and rebuild chimney to replicate existing. New chimney brick and mortar to match existing in color,
thickness, size and texture. No changes in color, material, design, location or outward appearance. Non-
applicable due to being in kind maintenance/replacement.
Dated: October 25 2010 SALEM MMISSION
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.