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105 DERBY ST - BUILDING JACKET �(f -70 � CK 4 ZZ`� qq sa W q 1 RAE:i D 312,0 I The Commonwealth of Massachusetts Board,of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,Ts edition OF SALEM Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling 4 e Wr: (!f O oi1,LTit` is 5 $uiltling Pennit.Numbert Signature: ' BwldipgCommtsstgne etof:gf$ � s; v ,.. " ate'„ ;- ... ' i� 1.1 Property Address:,,a 1.2 Assessors Map&Parcel Numbers 5 1.la Is this an accepted s V ye 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(it) 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❑ 1EC`1'i©N Y, gYtO ,` 1N3Y$AIPi 2.1 Owners of Record: Name(Print) !! Address for Service: Signature Telephone S�CTIUN 3 T�Eb"CittP [tom©F, IFC1P(1SE WORfz(ctieck all that apply) . . _... ._ New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Cl Specify: Brief Description of Proposed Work': SECTION 4 ESTI1kiAlll CO1YSTlUI TT[UN COSTS' Item Estimated Costs Labor and Materials gfroko Use Only 1.Building $ l ;Bml m PemtuPee:.$' Indicate how fee is.determined: _ ,. g. ,, 2.Electrical -$ S(andard t ti$/Town Avolidation-Fee [ TotaC) 1eCgst�,(Itein 6)x multiplier x 3.Plumbing $ z. fltt�er`lfte§k 4.Mechanical (HVAC) $ ff ck 5.Mechanical (Fire Su pp $ �,To1ahAltFaesr� G eck No Check Amount: Cash Amount: 6,Total Project Cost: $ b�j� ❑'Pmd tnF'ull' q:0utstanding Balance Due: Sys y ( 3 5.1 Licensed Construction Supervisor(CSL) -� �� 41, _ / License Number E L �\�� Expiration Date Name of CSL-Holder1 List CSL Type(see below) y q , Address) T� U Unrestricted u to 35,000 Cu.Ft. 1 It 16&41 � AX - R Restricted 1&2Famil Dwelling Sig nature nature M Maso Onl ion s-s3.13 RC Res idential R--fi"o Coverin Telephone -i_ �,` ; - \ WS. Residential Window and Sidin ` SF Residential Solid Fuel Bumin A liance Installation 1 D Residential Demolition 5.2 R stere t H_ e I tprovement Contract r IC) G. Registration Number HIC Cotppan Name or C Re t me Addres4 Expiration Date A 7 J 7�-761, - 31�t Signature Telephone SECTION 6 WOI2ICERS'CO11IP7 NS}Ti©Nul(NSYIRANCE AFFIIIAVTI (M G b c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide i will result in the denial of the Issuance of the building permit. this affidav t Signed Affidavit Attached? Yes .. No ❑ :SECTION 7a:Ul't'NER=ALITII4)I3ItA'P�ON+, ';13t�C M�L� ll W'HEN, :; OWIYER'.S AGENT OR.ivONTR�CTbR APIi�iI�3 POR R: IN'�'-YE _ as Owner of the subject property hereby to act on my behalf,in all matters authorize relative to work authorized by this buildin permit application. Si nature of Owner Date f . as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. l Print Name Signature of Owner or Authorized Agent Date - Si ned under the erns and enalhes of er u 1. s 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count fire Number of bedrooms Number of fireplaces Number ofhalf/baths Number of bathrooms Type of heating system. Number of decks/porches Enclosed Type of cooling system Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" 4 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM Revised January Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 (� One-or Two Family Dwelling �\ This Sectwn Fof Qffimal Use, my Building,Pennit,,Numbec Date Apphedt: Signature /7 iD/"d -Building Commi 'oner I pectorofBttildmgs,, '- .„„Date" SECTIO_N 1 SITE',INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.Ia Is this an accepted street?ye 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? Check if yes❑ Municipal❑ On site disposal system ❑ SECTIONS PROPEILTY-O�WNERSHIP-r 2.1 Own 'of Record: Name(Print) Address for Service: < 6- 2 - - 23� Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work?: A'' SECTION 4: ESTIMATED`CONSTRUCTION COSTS Item Estimated Costs: Official Use Onl Labor and Materials Y 1.Building $ 1. Building Permit Fee: $ 'Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town ApplicationTee ❑Total Project Coat'=,(Item.b)x;multiplier x 3.Plumbing $ 2. OtherFees $, 4.Mechanical (HVAC) $ List. 5.Mechanical (Fire Suppression) $ Total AIIFees $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ S ❑Paid,m Full ❑ Outstanding Balance Due: SECTI0N,5 =CONSTRUCTION+SER,YICES r, 5.1 Licensed Construction Supervisor(CSL) 7 7 ( r M ( if L License Number Expiration Date Name of CSL-Holder (/ List CSL Type(see below) w t L,-w UU SC:Qeit` Address n Type D'escri tion �� ,�� U Unrestricted(up to 35,000 Cu.Ft. —�-� R Restricted 1&2 Family Dwelling Signature`. M Mmonry Only 3 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Ite 'stere H to I tprovement Contractor IC) �0 HIC Co +Name or C Reg t ne G-. Registration Number c Address. - 7 -,c2-5� el e", �j �k-�C,C,fQ'�� Expiration Date Signature / Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAyIT,(NLG.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. t Signed Affidavit Attached? Yes .......... No...........❑ SECTION7a: OWNER AUTHORIZATION;FO BE COMPLETED WHEN . 6 'OWNER'S: GENTT'OR:CONTRACT/T�ORAPELIESiFOR�BUItDING`P.ERMIT y' Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date c �J SECCTION 7b-OWNER'OR AUTHORIZED AGENT DECLARATION` as Owner or Authorized Agent hereby declare that the statements and information-on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name J Signature of Owner or Authorized Agpt ` Da Si ned.under the vains and penalties of perjury) �-' 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors 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" 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 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: 105 Derby Street Name of Record Owner: Patrick McCormack Description of Work Proposed: Installation of new, 3-tab, charcoal grey roof to replicate existing. No changes in color, material, design, location or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: October 25, 2010 S L COMMISSION By: 71 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.