0060 DERBY STREET BUILDING JACKET C�� ly }ice
,r WT-gE f4Lf 4AG *P'PROVED BY 744E
JdSPJ:C=P81GII TD A.PEI31�ff BEwG GRANTED
y//� CITY OF_SALEM
,1-
s
Is Propany Located to Location of
tlw H WAft DisbW Yes--4/—No_ Building 6 Dole
Is Propwty Located In
do ConswvWpn Ana? Yft No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Conatnxl Dark, Shed, Pool,
RelwMeplace, Other: oydw P MA-.30,UQ
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name 1*1 e Llnc DAV 1-0 !t- wecD
Address & Phone l,Q 2�� S� f 7�159Y
Architect's Name
Address & Phone j 1
Mechanics Name
Address & Phone
What Is ttw purpose of W*W
tdalwial a buYdktp? Fb cr n a dwairg,for how mmy famon? /
Wo O AWN corNorm to law? Asbwpos?
EtlhmW cost 1V4 [j — City Licaruw s N A ss• G
Hoe isprovmant
Lie. fi x7W
re of Applicant
SKMED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
/(� ! $•t�R'P�A�np�P �J xlcS i.4-a�fl l��Plctc��,1.
MAIL PERMIT TO: 3/ Zec vtS PQ ��A�Yi co LY
.t.
No.
APPLICATION FOR
PERNT TO
01"Ile
LOCAT1 N
PERMIT GRANTED
INSPECTOR OF BUILDINGS
R
y<
,i
. 4 j.
_ -- - - --- _ 05
J fhe (lnonlonweetlth of .1lascaihusens -- —
y t Board of Boddmg Regtil ikons and StanJ:(rds ft It
,� Slas>di husells State Budding ('Ode- 7NO ( 'NIR. 7"'edition 111 \ll II' \I I I 1
C� 13uilJin_ 1'erinit Applii:nion To ('tmartio. Repair. Rrnoc.tle )l I)enluli.lt ,i RI I „• .l 4„ ,,,I
v 1 OnC- Ilr %LII-
hluttilrOnrllint• / _„r,.v'
I his .Section For Official (Sc t)illy f
Building Permit .V umher0.1te Applied
lure
(-� I Bwldmf('umini,.imiu
1.1 Pro_ "tiPION I: .SITE 1\1EUlitM% HIN
perty \ddreas --- "----------- - - .
1 1.2 %%sessors Slap & Parcel Numbers
--"—
I.la Is this an ace epleJ slrcU' ses___.— nu Maly "Llillher P.u.CI \umhC,
._ 1 1.3 Tuning information: t -1 Property Dir„rrsiuns:
I
1.5 UnAding (ft) --L_
!
F; nr; yard ; S'dr y and Rcur
t — ---
R' gun a Pn_,1,106 Required Pru,id•:d _ _ ..
� R yuirrd I i "3 d.d
1.6 Water Supply: i1t G L, 1C g 51) 17 f'loI Zoue Information: LS `ew _ Disposal--
ۥ Sy-stet r.
Public❑ Pncate u Z°ne _ Outside Fhxvd Zone:'
_Check if yes❑ 7 (}n n, tlisp-isal .,,wim
—. —
SECTION 2: PROPERTY OWNERSHIP' -- — �
--— — ----
2.1 Cwnert of Rt ecrd: — ----
!-\._dName(Print I
Address :or Sers'R.e:
Sigri:n:rc__ - _ _ 1'•I�Ph 'ir $ Sq`1 5 _-----_-_ _
SECTION 3 D: ESC'PIP"LION OF PROPOSED 1VORKZ(check all that apply)
--// —
New Cur.,Vu.a i,3n ❑ 8suimg 8ur!ding ❑ Owner-Occupied ❑ Rep:ursts) Gy ! Aher;itunas) ❑ Addrinul C
�_—_
De mol t m ❑ ( P.ressut y..3;d N. O Number of Units '--
! - - Other ❑ Specify -----------
I Brief De ripoon Iv .p d \L '
SECTION J: STOIATED CONSTRUCTION COSTS —�
Estunated Cnsts. -{
bem Official Use Only
i Lahor and Maferia;si
1 IiurlJ mg S 1. Building Permit Fee: S__ Indicate hoss ice I, dcici nuncJ -
'. filectnial •� ------~ ❑ Standard C'ity/Town :\pphcanon Fee
—a ❑Total Project Cost' 1llem GI < mulnplicr c .
). Plumbing S '. Other Fees S
1 Nfechamc.li iM .\C'I S
! i Slechameal iFur —.—_. - - ---
lu stress.... ) fIrt.il :111 Feet 5
ft�_ Check No l'hrck .Am�nlnt ( ', ,
�r total Project Cult 1 C/ G�Q -- --- h \ni uni
I / ❑ Paid in Full Cl Ount.indnie B.il.m,e I hlc
--
---- --_---------� .'
-012
It
2 Registered
Sivilalute
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. v. 152. 9 25C("
Workers Compensation Insurance athdavil must
this aftidavit %vIII result In the dental ot (he Issuanceol the building permit,
SECTION 7a: OWNER AU rRORIZA-1 IES FOR BUILDING PERMIT
`
�
'
! � x^0�oer ``t the `«h|�uP»`Pc//y hereby |
� |� __----_____-_-__---------'----- �v �u ,o /x� ,`|`^|[ o. ^|| m^m/`
^ �
iu��.mz� --'------�
authorized hythithoi|Jingpe/mx ^ppocu".". .
Daw
`
behal
` We
� Print N.,ine
pr(-gram or guaranty land under Ni G L c, I-42A. (tiller importan Regulations I HYROand 1 10 RS. o:,IIc,II%ek
|
i ^.`rki, pbnn�^ p*``«rm� m"«"'^"", "`-' /� J k ., |^...h/ /
� � vvx�o .up,umu � //n�!uJm� Lara�c hm,ked �:,c'o«` mu`� �, ` '
| T.vj| V~ rs area 'S4 hI R^h//^N' /°`m `"oo� --_-_'--��----- -'-
/ 6^^. |^my ,'�� '�o� F/ / SIwoher "|hI:J^wm`
| Numher '' »»/P\a/es ---' Nomhc/.,, |v|chxh` -_ - - �- -
S "mhe/,| hthx^`m, ----- Nm.`be/ ../ .|c`k`/ |*/`hc` -
�' i\|`e .`thc*nLl `\`uw -- -----
|\}v >`um -_------_---______ _
_---- ~
)
r �
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(rctluired litr all demolition and renovation work)
In accordance %%ill) the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debtis, and the provisions of MGL c 40, S 54;
Building Permit is issued with the condition that the debris resulting from
this %york shall he disposed of in a properly licensed waste disposal Facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
1 name of hauler)
The debris will be disposed of in
~ �— (name of taclhty)
.. (add •SS of lacilily)
ylalule of permit applicant
L J
'late —
r
(� The C'ommonweaIth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
L, Re ri.rrd.i fur 2011
Building Permit Application To Construct, Repair, Renovate Or Den ' h a
One-or Taw-Famd.l,Diveltime
This Section For Offic' Use Onl
Building Permit Number: Dat Applied: \
Building 01)ieial(Print Nmne) Signature Dole
SECTION 1:SITE INFORMATI N
i.l Pr perty JJress: 1.2 Assessors Nla reel Numbers
�12 �• �� yT
1.la Is this an accepted street?yes_ no Map Number Parcel Numtxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propo 0,(ke Lot Area IN 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al ❑ On site disposals)s stem ❑
Check if es❑ p pos" )'
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Mum(Print) C uy.Slate,!.I
�D O —Pe Am w S (r eS —2 0 b T
No.and Street treet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check What apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repatrs(s) Alterations) C1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Descripticq of Pr posed Work=: O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ltcm Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S V J-0 1. Building Permit Fee: 5 Indicate how f'ee is determined:
2. Electrical S Cl Standard City/Town Application Fee
❑Total Project Cost Item 6)x multiplier x
i. Plumbing S 1 1 p --
_. Other Fees: S
4. \lechanical III\':\('I S List:_-_
t Mechanical (Fire — - --- —
Su iressiont S Total All Fees:S_
2 G. Total Project Cult S �/ �3 Check No. _('heck Amount: ---Cash Amount:
/ ❑Paid in Full ❑Outstanding Balance Due: —
F
SECTION 5: CONSTRUcTiON SERVICES
5.1 Construction Supervisor License(C'SL) Z
I.icense Nm..tu F_xpiration
Daw
N;une UI' 'SI. I folder I V
ListCSl. f)pe(see hclUwl__�
'h)pe Description
NU. and-Street
/J/]/� // It t htrestricied(Buiidin�s ti to 35,000 cu. tl.)
/ � R Restricted L�?Pamil Dwcllin
Cityfl'oon,.Statc.ZIP NI Nlasonry
RC Rooling CoN'erin
-_ W:S Window and Siding
SF Solid Fuel Burning Applianceg
1 Insulation
'ele hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) t 31Za .?M �0'p NG�IQ�t��f/1� IIIC Registration tiion Number I!spiration Date
(jf1npany Name or I fl 'Regis[ •nt Numc
o �R (�
o.and Sue /� Email address
Ulu
Oa/Town. Stat ,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 15C(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 .......... e No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
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 in this application is true and accurate to the best of my knowledge and understanding.
PerimOtt cr's or,\uthorizcd Agents Numc I lilcctnmic Signauae) Date
NOTES:
I. :kn 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
Information on the Construction Supervisor License can be found at
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement attics,decks or porch)
Gross lining area(sq. tl.) _ _ Habitable room count
\m»beroffireplaces _ _ Number of bedrooms
Number of bathrooms N'umberothaltbaths -
1)pe of heating s)stem . . _ ._._---_ -- _ Number of decks, porches
1\pe of cooling s)stetn Enclosed --_ Open
} •'Total Project Square Footage-may be Substituted for"Fo(al Project Cost'
/� rn
� 9q�„ON617.1N
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:
❑ 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
Address of Property: 60 Derby Street
Name of Record Owner: Gina Atwood
Description of Work Proposed:
Repair/replace clapboards,frieze boards and windows (wood, 616, true divided light) to replicate existing. No
changes in color, material, design, location or outivard appearance. Non-applicahle due to being in kind
maintenance/replacement
Dated: August 23, 201 l SALE1 OMMISSION
By: /
fhe 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.
Tf IIS IS NOT A 13LJILDING FERMI"f. 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,MA 01970
(978)745-9595 EXT. 311 FAX(978)740-0404
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission
Ordinance,application is hereby made for issuance of a Certificate of Non-Applicability for:
Construction Moving Reconstruction Alteration
Demolition Painting Sign Other
as described below.
District: -Pe-R 6b 97- Original Building Construction Date,if known: 400
Address of Property: 460, T�B�iJG S
Name of Record Owner(s): 6r h* 42tU11*0 D
Descriotion of Work Proposed:
Signature of Owner: Jy_ ,._� Tel. #: q}&- 'SINK- � }Z&
Mailing address: �Or� ��cs City: O State Zip:02LL
Gina Atwood, 60 Derby St, Salem MA., 01970
Remove and replace approximately 900 sq feet of existing rotted clapboards (see photo
1).New clapboards will be of the exact same size and type as existing. Once painted
they will appear to be identical. Some frieze boards will be replaced and will have lead
flashing over the top of them to match existing frieze boards on the house (see photo 2).
Remove and replace 18 windows in the home. Some of the windows in the home have
already been replaced with JB Sash wood windows, 6 over 6. The remaining windows
that we will be replacing will again be JB Sash wood windows, 6/6,true divided light
which will replicate existing in terms of size, look and material. All windows will be
painted to replicate existing. There is one window in the kitchen which is currently 4
over 4 and will be replaced in kind with a 4/4 true divided light JB Sash wood window.
See photo of old window(see photo 3) and photo of an existing new window(see photo
4). All of the 18 windows being replaced will look just like photo #4. Includes new
casings and exterior sills to match existing in size, look and material. Includes copper
flashing on cap above window casing.
Owner obtained a Cert of non-applicability dated 9/15/08 to replace some of the windows
and did so at that time. These 18 windows will replace all of the remaining older
windows.
Storm windows will also be installed over the new windows as was done in previous
window replacements(see photo 4). Storm windows will replicate existing to greatest
extent possible in terms of color, appearance and material.
I don't believe storm doors fall under the jurisdiction of the Historic Commission, but in
keeping with full disclosure, I wanted you know that we will be installing two new storm
doors; one on the front and one on the rear. They will be full view glass doors with white
aluminum frames.
Gary Morrison, CR
Certified Remodeler
Morrison Remodeling and Repairs LLC
978-804-9597
- _ --
PUBLIC PROPERTY
C� DEPARTMENT
KINW M-EY DRISCOLL
SUroa 121 WwtINGrON N'MEEr 'Snitla,MASSAGiI;ShTIS 01970
lft 978-74S-959S*F,ut:978.740-9U6
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR DUMPING
1.0 SITE INFORMATION
Location Name: Building:
PropertYAddress:�j---�E�,2i4`/-ST; ------
Property is located in a; Conservation Area Y/N_�j Historic District Y/N _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: t6llyll . ._a
Address: 60 S7;
,5 keyo MA 01176
Telephone: 79'- _$72
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use I/ New
Demolition Existing '91 q00
Approximate year of /740 Area per floor (sf) Renovated
construction or renovation Y.1,2 of
of existing building I e0,z.1X()CQ New
Brief Description of Proposed Work:
00n/VWj_ k f_T ff n i6r7 -0 G6-A/C7'M L 100�1006EXAVN4�ey 12 OM 6Y
j� owl�G CvuM7 s� s/(Irk) Av'J FrXrW<✓ ' f4�,Jn A2�(J
INS IY�(� �f C�✓�OUC 0(/tom CJ /S17/VL W41 t lS, (04�.Rr3L-
Mail Permit to: AAvl,6 1- 6 1"A ooC1 GO Y ST, A0 01470
What is the current use of the Building? 1I
Material of Building? WOO 1\ If dwelling, how many units? -7 /
Will the Building Conform to Law? Y(is Asbestos? AA2A(6:
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ Wo Permit Fee Calculation
Permit Fee$_ 7o Estimated Cost X$741000 Residential
Estimated Cost-X$11/$1000-Commercial - --
An Additional $5.00 is added as an
I
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to b d to the above led
specifications. Signed under penalty of perjury X I p
Date ( t 6 Q
VN
O S
,nl
d
F a s• °o i
a a
CITY OF SALEM
PUBLIC PROPERTY
DEPART
MENT
KIMBERLEY DRISCOLL
MAYOR
12D WASHINGTON STREET•SALEAI,MASSACHUSEi'IS 01970
Tki 978-745-9595 • FAX:978-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date L 1 9' j 7
Job Location (�56 U-7eg y S 1
Home Owner Address S
Home Owner Telephone _95r 7 - Sery — c, z�7 Q
Present Mailing Address SAmr.- jq5 fh'111g"
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum in
spection ns cction cedures and P p requ' ements and that he/she
will comply with said procedures and req ' en .
HOMEOWNERS SIGNATURE
APPROVAL OF EUILDING INSPECTOR
See other side for state code
Homeowner's Exemytion
The Code states that: "Any Homeowner performing work for which a Building Permit is
required shall be exempt from the provisions of this section(Section 109.1 —Licensing of
Construction Supervisors),provided that a Homeowner engages a person(s) for hire to do
such work, and the Homeowner shall act as Supervisor."
Many Homeowners who use this exemption are unaware that they are assuming the
responsibilities of a Supervisor(see Appendix Q,Rules and Regulations for Licensing of
Construction Supervisors, Section 2.15). This lack of awareness often results in serious
problems, particularly when the Homeowner hires unlicensed persons. In this case your
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require, as part of the Permit Application, that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.
j,
UW OF SALE►M
PUBLIC PROPEM
DEPASTUENT
-to -.
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The �!� hWGby apPlMs for a pennk to build smxfto tl».fokow v
Owners Name r tvA o !�
A*hu A Plrorre
AmhkWs Name
Address A Phone t
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Address A Phone t 1
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MA O1970
TEL. (976)745-9595 ExT. 380
40 FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
in accordance with the provisions of MGL c 40, S34,I aelmowledge that as a condition
of Building Peanut# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S 150A.
The debris will be disposed of at:
Location of Facility
-/Ca"-// / 2 s- /M� 20
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
50 G�-rCH E-u W&Y C'4n/n A( ti1,4 0 zo 21
Address,City& State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL 01, S 150A, and the building permits or licenses are to
indicate the location of the facility.
1
QTY OF SALEM
BIJ wiNrjDEPARTivW
HOMEOWNER UCENSE FM•DON
Pkm Pda
>OB LOCAT]Ot/ o D 13�/ S i S 1� CrM tNl/� Q 19 7 0
�2(��/ s�. c�r -
Ha,,zo*mt
TafPilM
rxESErrruAn>r!o ADDI s �rc�2t2t/ S� < t.ccrv� M b r9 7 0
The emsad.oasptm d-lwmwwacw was aaeadee w bidade seaet-OMpM&mW&p OTWO
thsia a lac and a a)bw suds horseowsas m a�ppe m tadivWull is hits who dace vat posses� .
liccvn rw w dm do ewasr ad as sapervfeae.
DmmgnONCFHONWX)WM*
• Pcrsov(s)wpo owro•pared d land oa whkfi hchbe reside a brads to tesiee.tip�dddt� s��M
dad
bua is!e.•am to two firmly dwetlbq.smadtod a dcumcbw swucwa 7 00
krm svacwm A penm who eoasyum mcm tiara oae home b►a Wolf PC&A"MU saasidaad
Bm7dh>=ODk+alsSuehgo hch nVcwllb an�w�mk�pa OWAk�e tw a pu=L
me imdasigncd-homvmmf&wants rapmaft SO'for wmpftm whh the stale BvB tt coati d
o ha appliabk`oes by-into,rats as tegWwJaaL
The tvdasip w-mvaowed-=dfas shoe hehhe mdastanb the aw of salsa Bwwbg DepaoMl
miaimms msp= n picccdaes sad and that hhba will wilts said proadms d
Hotaowmis S1GNA
APPROVAL OF BMDDdG INSPECTOR v
$tic otha sick for sate Cade
5
HOMEOWNER'S EXEMPTION
- Tic code states that: •arq itoako.rncr yarorm .:v fa.+fib a boildbg Pcs rupbul dd k -
L%Cmyl from da pvvitioas of,bb section Owles>It19.Ll-3detnstsg d Constraetioa Sopavbert
1'tvwieaa that L s homeovrna�issa!P�+W(&)hbr 56e t&do.atr3 tM ais�bo®evtraa de:at
maq bomeownw svbo use tbfs cmmydm are immare*mt they are tuanmbg da vVcmdbWu oft
svpavim(see Appeodb Q,Rules and Regubrloss for lJc costog Constrrettss SgervieeM SGC*a
.2.1'M. This Jack of awareness Chen usuhs in sofas pobkno,pardconly�wbM the Looeoaa=hbo
milfeaased perstm[ 1n dds Case yom 8o&rd earatot prove ed&`abut Sec mme . potoa eat k vMv w!d
licensed Sopovlw. Ths boarcow•sir acting as supervYw Y oMbaMe�tes1wsyHltL
To same dm die homeowner b!fitly aware of bVhea respoasibMdek rsargr oomsomtltlss reePis;&&psst
of the permdl appltotio%that the homsowwaa cc:A r Om bahhe andastartOr the respaosbMIN eta
aupavbm: You msy can to amend and adopt suit a*rzatcri ieatim>br un In your
7 I'lie C•onumonwcal(h of Mwsachuscus
hoard ul'lluilding Regulations and Standards CI IN OF
I' :+
J9 Massachusetts State Building Code, 730(AIRS.\Ll:,\I
Re rimed Var_'rll/
Building Permit Application 'ro Construct, Repair. Renovate Or Demolish a
lble-urrwo-)ant. Uue/hikq
This Section For Official Use Only
Building Permit Number: Date Appli d: _
lhiilding 011icial(Print Name) Sig raturc Bale
SECTION I:SITE INFO MATION
1.1
.xin operl fis3): S? 1.2 Assessurs Msp Jt Parcel Numbers
I.la Is this an acce IM street?yes. no INfariNuniher Parcel NumlKr
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed Use Lot Arca(sq II) Frontage(11)
L! Bullding Setbacks(R)
Front Yard Side Yards Rea Yard
Required I'rovidud Required Provided Required Provided
1.6 Water apply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage DI ossl System-
flub Private❑ Zone: Outside Flood Lone?Check if yus❑ Municipd Fl On site disposal sf storm ❑
���,( Oy�eet� SECTION 3: PROPERTY OWNERSHIP'
C+%J/Xff rl a u7e1J r`�2: S�-e4 /yJ/��l Cr 70
N;unc(Print) City.Stoic.ZIP
NV�treel f dephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Arl Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ .Specify:
Grief Description of Pro osed \York':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Onl
(Labor and .Materials) y
I. Building S v I. Building Permit Fee: f Indicate how fee is determined:
'. Flacuical S ❑Standard CiryrTosen Application Fee
❑Total Project Cost'(Item 6)x multiplier
1. I'IumMng S ]. Other Fces: S
J. %1"lt.mic•d ill\.\('1 5 List:-- ----_ _-----c- �`
�. \leehanical (Fire S — ----
tit ++n•>sionl Total .\II Fces: S_
y t— ('he" \'o. ('heck Amount: _ Ca. h �\moot:
o Tidal Project Cust: 5 C J �� p Paid in Full 13 Outstanding BaLmce Doc:
SECTIONS: C'ONS1'RtUC'fION SERVIC'FS
5.1 ('unstructiun Su )ervisor License(C St.) —
I _ v
I iv ll c . Will I �piralion Date
N;unc ul .Sl. 11nldcr
PC Dctcriplion ..
N,1 nd SVccl
/}/ D U I 111 trile Ill•tcd I Bull Win ls a to iS,IIUO
_ /2 R HntricteJ ] P.Imil D++cllin
l'itsi fn++n,Stale.LIIK T�. .-- St %lasuu
G L.r� ) flV RC wilid C'urttiu
K N' o
f 'S indly mtJ Sidon
SF Y solid tion llurning Appliances I huulatiun
fcic hwl¢ P.nlail addreai D Dcmalitiun
5.2 Registered flume Impruveme it CuntrocIlar 11 C)
IIIC Itcgistnaiun Nunlhcr F%Piruliun Vile
11 C' 'al pitu Name or I IIC' Itagi r• a N me
N mrd, •e r 9.�'� Email address
h /Town, Sta a ZIP Talc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........C3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print O%wer s Name(Elccwnic Signature) Dute
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
coma' n this ap ' ati n is true and accurate to the best of my knowledge and understanding.
J
riot O++ner's�r: uthurircd Agcm's Nmne 11(lcctrunic Signaur¢) Dutc
NOTES:
1. .iln Owner vvhu obtains a building permit to do his.her uvvn work,or an owner who hires an unregistered cuntractor
mut registered in the Hume Improvement Contractor(HIC) Program). will nu have access to the arbitration
program or guaranty fund under%1.101. c. la_'.�.Other impunant information on the HIC Program can be found at
+1+1++ n+.n. ��+ .,t Information on
the Construction Supervisor License can be found at+1++++ In•h �; + Itr.
2. lien substantial work is planned,provide the int'unnatiun below:
f++tat flour area(sq. tl.l - __ I including garage. finished basement attics,decks or porch 1
Cross his ing area t sy. 11.1 ---- -- Habitable room count
\tuuhcrof'fireplaccs - -... Number ofhcdrooms .. .. -. . .
\umhcro)'hathrounu -- ._. _. —_ \wnbcroflhall'huths
I)pc ol'hcating s)stein Numher of decks, porches
11+
I\lie of coolillg i\>telll I!I1clPsed ..l dll
I "I octal Protect Slll arc Footace Illlll he wh>titutcd tllr,Total Project Gag••
_ CI-I'Y OF Sita-F-m, 1 wS:ICHUSEZTS
1 1,J BUILDING DEPAICOLENT
fit'# ;�� I• I� / 120 WASHLNGTON STREET, 3aa FLOOR
TEL (978) 735-9595
Rv((978) 7 W846
,�-I_NIBERLEY DRISCOLL
ALA YO Z T HOAU ST.P1E.RR8
DIRECTOR OF PUBLIC PROPERTY/131ai.DNO COSi:%IISS[ONER
Workers' Cumpensation fnsurance ,%tTfdaviti Builders/Contractors/Electrfelan,VPlumbers
%polleant Information ►ay//� Please Print Legibly
.V lllnetna.11lM',4l)f�anNallan.lNtIVIdIIAIJ: Lf[(/�/\/✓or/ IRY ®%�.�/ fj✓'j'(
T
Address: 0 p
City/StatcyZip: Phone M: — fD�� 7
Are u an employer'.'Check the appropriate box: Type of project(requlred):
I. I am a employer with 4. ❑ 1 am a general conlraclot and I 6. ❑Now construction
clllplayces(full and/or part-time).• have hired the sub•conlractors
2.El lam a sole proprietor or partner. listed on the altached.rheeL t 7. ❑Remodeling
..,hip and have no employees These sub contractors have V. Demolition
working liar me in any capacity. workers'comp. insurance. 9. Building addition
(No workers*.comp, insurance J. C] We are a corporation and its
required.) officers have exercised their 10•❑Electrical repair$or additions
).❑ I am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or udditions
myself.(No workers'comp. C. 152,11(4),and we have no 12.❑Roof repair
insurance required.) t vmpluyees. [No workers' IJ.[]Olher
sump,insurance required,)
'.%ny apptl,a,n dos cluck*bag It mws alw fill oul the wulios below showing(hair ratan'eompenwlun pulley innarmallom
'I L.nauwtwee who.ubmis this amdavil indieming they am doing all.writ and Thee him outside Contractors Mims mhmit a new m7fdavil indleuing.ash.
:fall rylun Thal Chuck this box mass machod an.tdlhnunat ahsrl ahuwing the nano of the akr'unlrsCWrs and Chair worltam'comp.policy Infomunnae.
fain was eurpluyer that la pravldbrX workers'eampduradon 6lsuranae far my eniplaydea. Below/s the poles and job site
ire/urtnutlne.
I n.,ururec(:untpany Name1�)'Le/V,/, r)�lj. x^ / Q
Policy 4 or Self•ins. Lie. 4:_T�—a 7't LI/ (�L'/J/ Expiration Dote�•,JD Z- Z�
sub Site Address: 0 R ce � — City/Stute/2ip:,�[`f
Anseh a copy of the workers'comps atiao pulley declaration page(showing the policy number and expiration data).
Ktilurts to wcura coverage as required under.Scetion 2JA ul'MOL c. 151 can Imd to the imposition of criminal penalties of a
tine up to il,500.00 ond/ur one-year impri.ennment, ar wall as civil pcnafties in the lorm of STOP WORK ORDER and a tine
of up to S_')O.UO a day against Cite violator. Ile advi.acd that a copy of this.,t atvment may but(urwurdcd to the 011ica uf`
Ltvc,li g.al ions of the DIA iur insurance covcragc vcri tic at iun.
/da hereby ratify rur✓er the pains mr✓prnulrlr.r i/parjury t/�ur the in�urnruNun pruvi✓a✓above it true uu✓carrdrR
ugtrc:
Uara:
IJ//iciv!uee July. /)J ode Ivrite LI thiv area, ra he cunrpl�te✓5y city ur town.rfjk iuL
City oe llnvn:. {'rrmitiLlcenae I_. .. _...._
thutinr.\ulharily (circle mac): - -
I. !bard III'Ileallh I Iluildln� 0VII10 anent 1. CilyiT-own Clerk J. Eleetric,ll 1n vt ttur i. Plnmbing (ntpeeror
0. 00wr
Phone,h
CITY OF S.1L &Nfo AUSACHUSETTS
JLtLDLNG CEP.ltmt8`T
120 W."KNGTON STIM, 1"FtOOR
rM k973) 745.9599
F.Vt(913) 1141
K13WER? ISY OR=CLL
MAYOR rkowf ST.PMAJL4
01RUTO110►PL eLlc PKCPLr tTY/eL:=CgG CO.%onssrG.v EX
Construction Debris Disposal Affidavit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section I I I.!
Debris, and the provisions of MGL a 40, S 34;
Building Permit At is issued with the condition that the debris resulting from
this work shall be-disposed of in a properly licensed waste disposal facility as defined by NIGL c
111. S 130A.
The debris will be transported by;
Jr u,f l: .P-e4f .:j-: nG
04me of hauler)
T'he debris will be disposed of in
(name or fac,lily)
( Jdrar oYf�c,t,�y)
+y arule o perrmrrppficant
!ire
•
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:
❑ 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: Derby Street
Address of Property: 60 Deft Street
Name of Record Owner: Sena Atwood
Description of Work Proposed:
Temporary removal of water table, toe kick, two plinth blocks and a minimal number of clapboards to facilitate
repair/replacement of rotted sill on front of house. Replacement of clapboards, toe kick and plinth blocks as
need to replicate existing. Reset granite steps and install new base. All work shall result in no changes in
color, material, design or outward appearance. Non-applicable due to being in kind
maintenance/repair/replacement.
Dated: March 15,2012 SALEM S SSION
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.