6 FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1\ Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date Applied:
Mir e• LV .7K..
Building Official(Print Name) Sign Date
SECTION 1:SITE INFO
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
G FSllE'fLAI_ CGttPyr 26-0.6-04
1.1 a Is this an accepted street?yes Y no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Q 2.
Zoning District Proposed U Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes0 Municipal DI On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord: FIEDGAAL CouRr REALTY S.4t 6M MA O19'jO
Joau F o M- a . 1c g r NA N. P AB 4 a F R HAea
Name(Print) 7"STfSS City,Slate,ZIP
-f3 cty4eT-se S7- 978--7-5-5"99I rc'r-Amrcf.5 pvexiien•
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building It Owner-Occupied ❑ Repairs(s) J4 I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
1Ze u r S o u dn.-hb a m to t2ct Qn
ell c cl
txr A "
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 31 goo , 00 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ fJ A ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ A( A 2. Other Fees: $
4.Mechanical (HVAC) $ IJ/A List:
5.Mechanical (Fire $ ��
Su ression A Total All Fees:$
0p Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 1600 . ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.tt.
Restricted 1&2 Family Dwelling
City/rown,State,ZIP Masonry
Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HtC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
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 ry n$' 0 Rh tr.t.L
to act on my behalf,in all matters relative to work authorized by this building permit application.
`4 3' . I�t.C�iAA06 Oc� . 26 , 20 /I
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERS 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.
`hta .,� off. ", 10 !l
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"
�gUNU1T
'P��mneaoN°
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: 6 Federal Court
Name of Record Owner: Federal Court Really Trust (Joanna N. Peahody F. Richards, Trustees)
Description of Work Proposed:
Repair ell chimney and north chimney of house to replicate existing. Mortar and brick to match existing in
color, texture, size and thickness.
Repair stone foundation of barn to replicate existing.
No changes in color, material, design, location or outward appearance. Non-applicable due to being in kind
maintenance/replacement.
Dated: September 6, 2011 SALEMJffST CAL 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.
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.