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the Commonwealth of Massachusetts INSPECTIONAL ERVdIWy%F
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR H14 NOV 10 egFeg4'r 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
l� One-or Tivo-Fmnily Divellhng
This Section For Official Use Only ..
Building Permit Number: Date App ed:
nuilding Otlicial(Pont Name), Signature- Date
SECTION 1:SITE'INFORrNIATiorc
1.1 Property Address: f// F� L2 Assessors binp&Parcel Numbers
r to d�
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
inning District Proposed Use Lot Area(sq tl) Frontage(It)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTYOWNERSRIP!`
2.1 Ownert or Record:
Ir
T -t 1 1 C P Q h br� S D 70
R�rnc(Print) y City,St7e`ZIP
r- Cl
Na.and Street Telephoa Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
v 7
SECTION a: ESTIh1ATED CONSTRUCTION COSTS
Itc n Estimated Costs: Official Use Only
Labor and Materials
I. Building S - I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier s
3. Plumbing S �%q. lherFees: S
4.Mechanical (HVAC) S - List:
5. \leehanical (Fire "total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount•.
6. Totai Project Cost: S (h ❑Paid in Full ❑Outstanding Balance Due:
f I l� C.t� F-'e C.ONDo t-vR
13� S S�Nr v-o I� o � SNrc�s(�a2v`
SECTIONS: CONSTRucTION SERVICES
5.1 Co ruction Supervisor License(CSL) 09 G 9 Z2 _ p —/ �
D f—1 P2C z 0 b2't License Number Expiration Date
Name of CSL Holder
t_7 Q_ n ` f_ List CSL'fype(see below)
1 w r1�t_ J l• Type - - Description
No.in Street D ^
Jt� lc,_ (,)' U Unrestricted(Buildingstip to 35,000 cu. IlJ
R Restricted I&2 Family Dwelling
Cityrfown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 (� ( Insulation
'rcie hone Emil address D Demolition
5.2 Registered HomeI Improve^�ent Contractor(HIC) f � � 9
(0 10 f (Z Y V ) Y 19 /Y i4- � +V tt 2 � U'0l HIC Registration Number Expiration Date
tII�C�mp:myQ(Or�p70 ngistrth0/,(\ t V1e 004 f
No. dtY,$ltfc l• t �� `` y� ��//tt1� �D( �G67 _ O1 3 Email address
Cit /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 nffidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ........ No...........Cl
SECTION 7a:OWNER AUTHORIZATlON:TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR B [LDING PERNI1T
1,as Owner of the subject property,hereby authorize l yl r l
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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
contained in this application is true and accura to the best of my knowledge and understanding.
Print Owner's or Authorized Agcnt's Name(Electronic ignature) Dute
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 nnr have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
www.rnas, ,( ort Information on the Construction Supervisor License can be found at wtvw.nmis. ,ov:'d . .
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. 11.) Habitable room count
Number f fireplaces Number of bedrooms
Number of bathrooms. Number of half)bnths
Type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open_
i. "Total Project Square Footage"may be substituted for"road Project Cost"
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The Commonwealth of Massachusetts I't`iPEG�
Board of Building Regulations and Standards �A�CITY OF ,0
Massachusetts State Building Code, 780 CMR i0(b JONe6iseu011
Building rmit Application To Construct, Repair,Renovate Or Demolish a
d ly p 0 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: - Do e Applied:
Building Official(Print Name) SignaturK Date
SECTION 1: SITE INFORMATION
1
1.1 Property Address: . 1.2 Assessors Map&Parcel Numbers
Z/�
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
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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oyw� ner of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work 2:
e 7ao f
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing 2. Other Fees: $ $�r��
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount: '
6. Total Project Cost: $ D3� Oo ❑Paid in Full ❑ Outstanding Balance Due:
C�.� �o aw►�it_ 6-�6��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�` 11�389 zYiB
License Number Expiration Date
Name of CSL Holder
` ?o List CSL Type(see below) (J
No.and Street /////Jlu� O' Type Description
�/t+/>OYd/I'!t-Old U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
6 SF Solid Fuel Burning Appliances
2-6 7-W f7,� I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
�o skw�s-�dv-�/
No.and Street /
787 97�� 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 Issuuance of the building permit.
Signed Affidavit Attached? Yes .......... ffnc 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 Z,dwP�nVeel-t Xllw—�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signal=) ate
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.
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.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"
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 District
Address of Property: 116 Federal Street
Name of Record Owner: Leach Nichols Condo Association
Description of Work Proposed:
Remove existing 3-tab asphalt shingle roof and replace with GAF Royal Sovereign 3-tab asphalt shingle
roof to match existing color.
There will be no changes in color, material, design, location or outward appearance.
Non-applicable due to being in-kind replacement.
Dated: May 23, 2016 SALEM HISTORICAL COMMISSION
By: 1 a, A i cs � k1— /
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.
Once completed,please submit a photograph(s) of the final result (maximum offour- i.e. one photograph of
each affected fafade).
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of