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173 FEDERAL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards TOE t� Massachusetts State Building Code, 780 CMR. T"edition TZlding Dept ` Building Permit Application To Construct. Repair, Renovate Or Demolish One- or Tyco-Furttth Dueffing This Section For Offtci se Only V1 Building Permit Number 4 Date Appl ed: -U 1 Signature: Building Commissioner/Inspector of Buildings DLe SECTION 1: SITE INFD"AT1ON 1.1 Property Address: f 3 r S� 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an acce led street,?yea n✓ o Map Number Parcel Number 1.3 Zoning Information: 22— 1.4 Property Dimensions: 2q[J�- Zoning District Proposed Use Lot Arcs(s n) Frontage(n) 1.3 Building Selbocks 0l) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water pply:(M.G.L c. 40.154) 1.7 Flood Zone Information. 1.8 Sewage Dbposal System: Zone: _ Outside Flood�2y��/� Public Private O Check if esO' Municipd On site disposol system O SECTION 2: PROPERTY OWNERSII.'Pt 2.1 Owneri of Reeord: 2 �iGnhQ Pile ALM"(et In 3 Qd S� Name(Print) p Addren for Service: signature Telephone SECTION 7: DESCRIPTI OF PROPOSED RKt(check W that apply) New Construction O Existing Building Owner-Occupied MI Repairs(s) brl Alteration(s) 0 Addition O Demolition O 1 Accessory Bids. O Number of Units 1 Other O Specify: Brief Description of Proposed Works: a " {x.Qita-I- df 02Ai w 0 11.-j 2 If SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. Building f I. Building Permit Fee: f Indicate how fee is determined. - '1-'Standard City/Town Application Fee 2 Electrical f O Total Project Costa(Item 6)a multiplier ■ J Plumbing f 2. Other Fees: f J. Mechanical IHVAC) f List: 5 Mechanical (Fire f Total All Fees: f Suppression) J�� �� Check No. _Check Amount Cash Amount:_ 6 Total Project Cost: S / 0 Paid in Full 0 Outstanding Balance Due: SECTION 3: CONSTRUCTION SERVICES 5.1 Licensed Construct Ion Supervisor(CSL) S. Liccnve Numlxr Evptration Dalc - .114rw ut CSL Hplder Li,i CSL Type(,cc below) Tvoc Description Addrrss U Unrestricted(up to 73,000 Cu. Ft. R Restricted Ih2 Family D%elLn Signature M Masonry Only RC Resdenti ofr al Ron Co vering w'Telephone S ResrJen ial Window and Sidmit SF Residential Solid Fuel Burning Appliance Installation D I Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or,HIC Registrant Name Registration Number Adding Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2SC(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 AfTdavit Attached? Yea.......... O No........... O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S ----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. Si nature of Owner Date SECTION 77b:OWNEW OR AUTHORIZED AGENT DECLARATION Q 4/141 1 X(( I AAA (A , 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.— 61C4hV1Q �fl Prim/Name -01 Signature of Owner or Authorized Agent Due Si tied under the pains and penalties ofperjury) 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 W have access to the arbitration program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R3, respectively. 2 When substantial work is planned, provide the information below Total floors arcs(Sq. FL) (including garage, finished basementlattics,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 Tvpe of cooling system Enclo,ed Open 1 `Total Prolecl Square Footage' may he ,uhmimcd for 'Total Project Cost" Il— CITY OF SALY-M PUBLIC PROPERTY DEPART' EN'T KAUWAL rOaMA" ,%"VM 1]0 4AYYNCTOM!near•SA►ia4 MASMO&SKM oN'0 TtL 9's•7+s.9s"P P.A]c 975-76904 HOMEOWNER LICENSE EXE.MMON Pies" /bust Date Job Loead" �f Home Owner Address Home Owner Telephone Present Mailing Address t The current exempdon of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who doer not possess a license,provided that the owner sets as Supervisor. W DEFINI ION OF HONMWNER pown(s) who owns a parcel of land on which he/she resides or intends to reside. on which there is, or is intended to be, a one or two family dwelling, attached or detached. structures accessory to such use and/or farm structures. A person who constructs 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 he/she be responsible for all such work performed under the Building PamiL The undersigned-homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she -grill comply with said procedures and requirements. ' I HOMEOWNERS SIGNATURE .s,PPROVAL OF BUILDNG INSPECTOR See other side for state code CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT Q j%W MIFI "NIti ''ll \t .,,„µ I_'C �'•�iI II\t.:,!V$I"$LCT • S•\I I-\I. fit.\�i.\till •1 I i :I'/ FFf: 'l7ti-74i:)iys 1°.\3:')7g-N3'1946 Construction Debris Disposal Affidavit (required I'ur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: Inamc ut Imuler) The debris will be disposed of in s AMC uf (n:un�e facility) (address ul facduy) oC �n�u Vl ►rl,u � L��. M� z-%t %ignature of permit�applicant date -t CITY OF S.UXUNt, AXSSACHi:SETTS BL'BDING DEP.IRT\lE.�iT • 11 0 WASFIINGTON STREET, Y°FLOOR TEL (978) 74S-9S95 FA .X(978) 740699" KIMBULLEY DRWOLL THObtASST.PMRM MAYOl< DIRECTOR OF PtBLIC PROPERTY/3VtLDLVG CO\LNBSSIONER Workers' Compensation Insurance Affidavit: guilders/Contractors/ElectrlcionsiPlumbers Alatslicant Information Please Print Letiblr �nl4 � na �lta /tfd4)G_t, Vatne IBloirn+s�Orgyrtntiotrin.bvlduaq: '• Address: /)T3 r�J <+ city/Statrrzip: JK LO WA AA�' Phone M: Are you an employer?Check the appropriate box: Type of project(requlre'd)• 1.Q 1 am a employer with 4. Q 1 am a general contractor and 1 P Yee 6. ❑New conatructitao employees(full and/or pan-time).• have hired the abca tractors 2.Q I am a sole proprietor or partner- listed on the attached shimL : 7. emakling .hip and have no employees These sub-contractors have V. ❑Demolition working for me in any capacity. workers'comp.insurnam 9. Q Building addition (No workers'comp. insurance S. Q We am a corporation and its rc red.) officers have exercised their IO.Q Electrical repairs or alh�itl m; 3, a homeowner doing all work right of exemption per MGL 11.❑Plumbing repair or additions myself.(No workers'comp. c. 152.11(4).and we have no 12•Q Roof repairs insurance required.)t employees.LNo workers' 13.Q Other comp. insurance required.] .Any appikam that chocb ben el mat also rap out Ilts mime below shrwida their worlea'cur"Matdon policy inf nviahilt. '1 hwwuwlm who sabaat this sAldwis indiottlry they at*doing all work and then hit*outside mamebn muss tuMnU a nnr aaldsvil indicriq attek <'.maayoM tha chock this box mats anwhad an 3"Ii mal than showing dw na net ottha sue.C' inia,,and diek ww4ts'romp.policy infotmadee, l am as employer that lr providing workers'compenmakn lnsttroaeefor my eseployetra Relate,is the potty attd/0t1 Sim informetlon. Insurance Company Name: Policy N or Self-ins. Lie. H: Expiration Date: Job Site Address: City/StawiZip: ,%rtack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year imprisonment.as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of I nvcatlgai ions at'llie DIA for insurance coverage vcritication. 1,10 hereby cop under tha pains and penalties ajperjury that the information provided above is rrug,and carrtea 1ZLU lttre:V 01'�V)vl� 0� l 0� AK P4 Gk Kara I zS a�► Phn s: _`'I D 7L., O/flria!we a.Jy: Do ear tvrin in rhir aver, ro lot:urnp/tted by city or/own o/JlriaL � City or ruwn: _ PcrmiNl.kcnse M—_.. __ Issuing.%ushurily (circle one): -- _ I. Ituard of ilvallh 2. Building Mpartment J.City/town Clerk 4. Electrical Inlpeclor 5. Plumbing Inipeetor 6. 1)lhtr LonlactPerson. _ __. Phones• Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978)740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition -1 L Painting ❑ Signage $, Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property- 173 Federal Street Name of Record Owner: Gianna DellaMonica Description of Work Proposed: Paint colors: Body color to be the same as 141 Federal Street (Sherwin Williams Renwick Heather) Trim to be California Paints DEC710 Peach Door andflower boxes to be California Paints #602 Installation ofsix wood window boxes per photograph submitted, to be full width of window and to reuse existing brackets. Dated: November 19, 2009 HISTORICAL 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. p Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978) 740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving IX 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- 173 Federal Street Name of Record Owner: Gianna DellaMonica Description of Work Proposed: Replacement of red, 3-tab asphalt roof to replicate existing. No changes in color, material, design or outward appearance. Non-applicable due to being in kind replacement/maintenance. Dated: November 19, 2009 SALEM HISTORICAL 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.