42 CHESTNUT ST - BUILDING PERMIT APP LA Z° CV,-IGG 6
The Commonwealth of Massachusetts ,' .
r:Nv y
Board of Building Regulations and Standardsdt
Ulf Massachusetts State Building Code,780 CMR ))pp p� Re iced Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demoll��2'0 P I2: Q 7
n One-or Two-Family Dwelling
�V This Section For Official Use Only
n0 Building Permit Number: Date Applied:
\`1
Building Official(Print Name) Signature Date
f� SECTION 1: SITE INFORMATION
1.1 Property Address u� 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes tloo�_ 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.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 O f Re o
Name(Print) City,State,ZIP 7
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Numb r of its_ I Other ❑ Specify:
B ' f ription of Pr posed W rk :
Y
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ C, Q 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Pro'ect Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other F es:
4. Mechanical (HVAC) $ " t"�
5.Mechanical (Fire $
Suppression) Total All es:
Check No. ck Amount: Cash Amount:
6. Total Project Cost: $ 2 oo fJ ❑Paid in Il ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 s ucHon Supervisor icense(CSL) 143a-FO 27 !7
'ay License Number Expiration ate
Name of CSL Holder
A,- List List CSL Type(see below)AK
(/
No.and S et Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town, to ZtP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I
�s Insulation
Telephone Email address D Demolition
5.2 tered Home Imep ovv ent Contractor(HIC)
C Registration Number Expiration Date
HICC a any HIC — L/Name
le(
N$-�nSdjsp'eet /` p� �Ji. / / , Email address
City/Town,State,ZIP Telephone
Z
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 ERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters re ti to work authorized by this building permit application.�
ry
Print Owner's Name(Electronic Signature) Date
SECTION 7b:,OWNER' 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 inth,�t application is��y curate to the best of my knowledge and understanding.
Print Owner's or Authorized Agen s Name(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�ov/oca/oca Information on the Construction Supervisor License can be found at www.mass�/ids
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" 0 v d
Salem Histot ical 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:
❑ Construction ❑ Moving
✓ 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 District
Address of Property: 42 Chestnut Street
Name of Record Owner: Ken Harris and Debra Glabeau
Description of Work Proposed:
Repair and/or replace damaged wood gutters,fascia, soffits and trim along eave. Install round copper
elbow to existing copper downspout.
All work to be in-kind with no changes in color, material, design, location or outward appearance.
Non-applicable due to being in-kind replacement.
Dated: October 13 2016 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.
Once completed,please submit a photograph(s) of the final result(maximum of four-i.e. one photograph of
each affected fagade).
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.