164 FEDERAL ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
se
this Secti!61i For Offlf-7ia n y,,
7"
Building Official(Print mKU
Date
>SECTION I:,SITE INIT
1.2 essors Map& Parcel Numbers
1.I 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,L§54) 1.7 Flood Zone InFo—rmation. 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑
Public 0 Private 0 Check if yesD
ST 777777-77_7_�
PRO PERT
.0'
tl OwnerioIR c
Name(PrimCity, State,ZIP
Itot C�. -e
S-v
No. and Street Telephone Email Address
�7 SECTION'M,DESCRIPTION OF PROPOSED W9 2 (check all that apply)
Repairs(s) 0 Alteration(s) 0 Addition 0
New Construction El Existing EBuildiing 0 Owner-Occupied 0 1
Demolition 0 Accessory Bldg. ED Number of Units— Other 0 Specify:
Brief Description of Proposed Work : C>
�
?N4: EST'IMA, �TED.CONSTRUCTIONS , COSTS',_,��',� ,
Estimated Costs: w . Official Use Only`
Item ( s Labor and Material
1. Building I Building gTer I mitFee- Indicate how feeds determined:-
Fee
2. Electrical L ....
[3 Tbtal"PeOjectC6!st3L(itern6)x.iiitiltiOlidt X
;,'�%� %
3. Plumbing
4. Mechanical (HVAC) Li'st
5. Mechanical (Fire
Suppression) To
Ch Check A m,6'Unt.
. I j .:Cash Amount
,;�'6. Total Project Cost: iOL) j 0 Paid in Full P Outstanding Balance Due-
SECTION 5r CONSTRUCTION SERVICES
rad
ruction Supervisor License(CSL)
License Number Expiration Date
L Holder
List CSL Type(see below)
et ,`�'Pe y Description
U I Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 FamilyDwelling
Ciry/Town, State,Z[P M Masonr
RC Roofin Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANGE'AFFH)AVIT(M.G[L c: l'S2i_§ 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 jai OWNER AUTHORIZATION TO BE COMPLETED.WHEN ,.
OWNER'SAGENT'ORCONTRACTOR 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.
Print Owner's Name(Electronic Signature) Date
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.
J ir�f✓iU IV��I'1\ Z
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.rnass.goy/oca Information on the Construction Supervisor License can be found at HAwy�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"
CITY OF SALE.Ni
PUBLIC PROPERTY
DEPARTMENT
U fOWfY DULL't7LL -
Vwvae IbwAwYMCfOMl7faR�SNJy VwfMOrl.t<TIf011'0
raL t-&745.15" V%X 973.7467e1e
HOMEOWNER LICENSE EXEINMION
Plea" Friel
Date I-A 0, 1x2_
JobLoeadoe llol-F ` A
Home OwnerAddrese \1g� t g-c � iI S Sf�n T ZauA I I-
Home Owner Telephone 5 5
Present Meiling Address \()LF 414 koCA cb\ e,'")o
The current exemption of"Homeownars"was extended to include owner-occupied
dwellings of two Units of less and to snow such homeowners to engage an individual for
hire who does not possess a licenser provided that the owner acts as supwAim.
DE INMON OF HOMEOWNER
Persons) who owns a pied of land on which hdshe resides or intends to reside. on
which there is, or is intended to be6 a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructe more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that hdshe be responsible for all such work performed under the Building
Permit
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
will comply with said procedures and requirements 2
HOMEOWNERS SIGNATURE 6—ytp c� Cam( f?o�
APPROVAL OF BUILDNG NSPECTOR
See other side for state code
CITY OF SM.E1d, TAxsSACHUSETI'S
• BUILDL\G DEPARTMtENT
130 WASHNGTON STREET, 3° FLOOR
TEL. (978) 745-9595
F.Am(978) 740-9846
KINtBFRr FY DRISCOi1
MAYORT7-iOM(AS S7.PIERR8
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 111.5
Debris, and the provisions of MGL 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:
oJ�tS�c� �.9a V'z.Tw�C,
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
elate
dcbrisal�.Iw
v���ONDIT4„�O'
'�'eiynvaoo
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: 164 Federal St.
Name of Record Owner: Donna & Peter Bimbo
Description of Work Proposed:
Repair/replace backporch to replicate existing. No changes in color, material, design, location or outward
appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: September 19, 2012 SALEM HI i O 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.