360 ESSEX ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State BuildingCode, 780 CMR, 7'"edition Wilbraham
Building Dept
�J Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Family Dwelling Ext 118
This Section For Official Use Only _ `
^^ Building Permit Numbe . Date Applied: a `j
�} ✓1 Signature: O!G
Buildinj Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
740 e5j;6,-,V crT d-41 t
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 it) 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 ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
CAar•le;M— I f B9f/.Oisr c36 C6F�—K fT Ol6�i�n.�
Name(P int) Address for Service:
q >a— 7 y6-- d�y�3'
Signature - Telephone
SECTION 3: DESCIA4PTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ �Specify: o _ E 1•;,,,�
Brief Description of Proposed Work': BQ� .,,Fr Oicn6T...e �tr r9 o/.a11�6A ..plat
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: SM Indicate how fee is determined:
tandard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check mount:��Cash Amount:
6. Total Project Cost: $ /,�� 99d"•Od ❑Paid in Full ❑Outstanding Balance Due:
J7
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) qw�V 7d O/
C urwi6n License Number Expuatron Date
Name of CSL-
Holder List CSL Type(see below) MI
—.2,-3 'Lr' ed Type Description
AddresZ /t U Unrestricted(u to 35,000 Cu. Ft.)
1, R Restricted 1&2 Family Dwelling
Sign ure M Mason Only
4 y-49D -vBl RC Residential Roofiny,Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) � �
Awn/1 .teaT /I y�r �
omber
HIC Company Name or HIC Registrant Name Registrationratton Nu
M6- p
Address -,lBl2o
Expiration ion -ate
Signature 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 building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 _(Z `� �„� ;� �2 �„�_ ,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
1 --ST
Si�ure of Owner or Authorized Agent Date
`Si ncd under the-airs 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 I I O.R6 and I I O.RS, 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
is herebv certified that the Salem Historical Commission has determined that the proposed:
7 Construction ❑ Moving
;-'� Reconstruction ❑ Alteration
Demolition ❑ Painting
Signage , ❑ Other Work
s described below does not involve an exterior architectural feature or involves a feature covered by the
xemptions or limitations set forth in tl*Histiic District's Act (M.G.L. Ch. 40C) and the Salem Historic
)istricts Ordinance.
)istricc Mclntir
Adress of'Property: 360 Essex Street
ame of Record Owner: Charlotte L. Freedherg_
)escription of Work Proposed:
eplace existing 3-tab roof with new 3-tab roof—either GAFSentine120 year, Royal Sovereign 15 year, or
/circlui.s i0 year life. Replacement o lashing to replicate existing. Replace 4louver vents in kind. All work to
plic ale existing. No changes in color, material, design or outward appearance. Non-applicable due to being
r kind maintenance/replacement.
,ated: October 9. 2008 SALEM I R I C 5 MMISSION
By.
he homeowner has the option not to commence the work (unless it relates to resolving an outstanding
iolation). All work commenced must be completed within one year from this date unless otherwise indicated.
I [IS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
uildings for any other necessary permits or approvals) prior to commencing work.