6 FEDERAL CT - BUILDING INSPECTION (4) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
SALEM
W Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two Family Dwelling
This: 'For Section, 0fficial Use:Only
,,
BuldirigPermitNumber ,, M�IJULU piled:
JF f ......
Building Official lrrmt,Name >s`Signature a Date
SECTION,I: SITE NFOItMA
1.1 P//roperty Addr e 1.2 Assessors Map a el Numbers
1.1 a 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—ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
F_R,,,C,,,d 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 0 Private El Zone: Outside Flood Zone? Municipal El On site disposal system El
Check if yesO
SECTION 2:' PR
OPERTY HIP
2.1 Ownert of Recor
r%,% A ;ntl"Vc�s 9,
Name(Print) City, State,ZIP
zkwj- a n 71!3 1 q!A!A
No.and Street Telephone Email Address
---------------7-777---7��
C -th
SECTION DESCRIPTIONOF, W
S OW(check al'I
'I at-apply)'
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) El Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other El Specify:
Brief Description of Proposed Work':_Wfr, Tzcbg--
S E! TI TEWCON�T4V q;�SECTION 4: Esq Cos
Estimated Costs: 11 ' , : " '. Offlcial-U.w OnI
Item (Labor and Materials) ,, ,
1. Building $ 1: Buildi)hg�PetmifFoe. $ Indicate how fee.isbe!cj iijed:
El Standard'City/Toivii Application Fee -
.
2. Electrical $
❑'Tot I- r6i6dt CostPtem,6j-x,mulhphdr x
3. Plumbing Oth $ �t <r e
4, Mechanical (HVAC) $ ist
5. Mechanical (Fire
$ TotalAJILF
_L mession) Fees: $
Check No. Check Pr Amount: Cash Amount:.,�
6. Total Project Cost: $
P Paid in Full L9, 0 Outstanding Balance Due: L
—SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL) (Z oia'I-VA 1 10 a0 JLJ
9Amsp- �'�' License Number E piration Date
Name orCSL Holder
t9M List CSL Type(see below)
Palk,
No. and Street it .
' .Type ��'"Descn pt tOnC;
U Unrestricted(Buildings u 2 to 35,000 cu. ft.)
l►JV`�CS M A �,� R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Ack-GM I Insulation
ele hone Email address D Demolition
5.2(�Registered t;Ho/mme Improvement Contractor(HIC) ` �yy 013
HIC Registration Number E pi tion Date
HIC Company Name or HIC Registrant Name e-
No„�nd Street ' �S Email address
wt7`PXS M d
City/Town, State, ZIP 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'
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: OWNERt'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.
V 0 4-,Z 1- Pe tt- t,) 0
Print Owner's or Authorized Agent'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.gov/oca Information on the Construction Supervisor License can be found at www.ntass.eov;'dns
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"may be substituted for"Total Project Cost"
y
CITY OF SALEM, UxsSACHUSE-FrS
a BUILDL\G DEPARTMEINT
t3.c 130 WASHCYGTON STREET, 3° FLOOR
TEL (978) 745-9595
Fnx(978) 740-9846
KI�tBERLF-Y DRISCOLL
i1iLiYOR THOAtAS ST.PIERRB
DIRECTOR OF PLSLIC PROPERTY/BI:nmmc;CO`WIS5IONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
—
(name of facility)
(address of facility) `^ +
C \----,r� h./ ♦may/�/ V
st azure of permit applicant
date
dcbns�U:dx
v
Salem ist®rieal Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETfS 01970
(978) 619-5685 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem L-Iistorical Commission has determined that the proposed:
❑ Construction ❑ Moving
-Z 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: 6 Federal Court
Name of Record Owner: Joanna N Peabody & Mary F. Richards Trustees Federal o r R al y Tr 1s
Description of Work Proposed:
Rerool"South side of hare, upper section to replicate existing(3-tab charcoal asphalt). No changes in color,
material, design, location or outward appearance. Non-applicahle clue to being in kind
irrainienance/r•eplacernent.
Dated: November I, 2012 SA/FlR OMMISSION
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 frorn this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits tiom the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
II
CITY OF Si ll.E1I, NLxss:ICHusETTS
BL'IL.DING DEPART\(E.NT
120 WASHINGTON STREET, 31D FLOOR
TEL (978) 745-9595
F.ke(978) 740.9846
KIJIBFRf FY DRISCOLL
MAYOR THontAS StPIExRs
DIRECTOROF PUBLIC PROPERTY/BUILDIING CMINJISSIONER
Workers' Ctnnpensation insurance Affidavit. Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Norris(Business Organizaiiorvindividuaq:
Address:_q Le I A ) 1!tN I+-A " Sf -
city/State/zip: dl�U C1�S "fMdk Phone H:
Are ynu an employer?Check t e appropriate box: 'Type of project(required):
1.RJ 1 am a employer with 4• ❑ 1 am a general contractor and i
employees(fLll and/or part-time)." have hired the sub-contractor 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 9. J]Demolition
working fur me in any capacity. workers'camp.Insurance. 9. Building addition
(No workers'comp,insurance S. [] We are a corporation and in
10.❑ Electrical repairs or addi[iona
officers occrs have exercised their '
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152, )1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[A'o workers' 13.Q Othcr
camp,insurance rcquircd.)
•Any applicam s that chocks box e I rest also fill uut the atttion below showing their workus'wmpenudun pull infurmatton.
'Ih. ,uawm"who ouhmil this aMclavit indicating they am doing all work and then hire outside contract=must submit a now aMd2vit indicaing such.
:Commuters Thal chick This box men anachod an a durad shed shu wing the name of the suttaendactore and Iheir wurkem'wmp.put icy infom ujca.
l am un employer IhaNe provldlnA workers'compeneadon Insurance jar my emplayeex Below is rile pollcy and Job site
iofertnalfon.
insurance Company Name:
Policy 4 or Self-iris. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section I3A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line
of up to S250.00 a Jay against the violator. Be advised that a copy of this statement may Ix:furwarded to the Office of
Investigations of ilia DIA for insurance coverage verification.
I do hereby certify under the pulps and peaulNer ufpeijary rival the htfuraturion provided above is true and carreeR
iienalllr2, Dote:
Phone,l•
OJjicial use wady. Do nar write in thlr urea,to he compleled by city or town alj7clal
I
Cityar,rown, _ Permit/I.Icense{f __
Issuing Authority(circle one):
I. uoard of ilealth 2. nisi ding Departnteul J.C.ilyfrown Clerk 4. Electrical al
5. Plumbing Inspector
6.Other
Contact Persnnt. _._ __._._ ._._ Phone il'