180A FEDERAL ST - BUILDING INSPECTION 2SZ sc
The Commomvealth of Massachusetts RECEIVED
VS'1 Board of Building Regulations and StandaMPECTIONAL SE VIC�TY OF
Massachusetts State Building Code, 780 CMR Rev 9AM M2011
Building Permit Application To Construct, Repair, Renovaathr NkYnolth P 5 21
One-or Two-Family Dwelling
This Section For Official U Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property AJJres 1.2 Assessors Map& Parcel Numbers
—ice S{
L la Is this an accepted street?yes r/_" nc Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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'?Check if ycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1O caner'of RecorJ: "
Name(Print) -� City,State,ZIP
/'KL) Y1 I k-x. �l -� U/(' YSZ-S�6
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify-
Brief Des iption of Propo(�d Work''
I
a V i SECTION 4: ESTIMATED CONSTRUCTION C
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ e 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ �� ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ f)Od 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
/ Check No. Check Amount: Cash Amount:
6.Total Project Cost: �G /�� ❑ Paid in Full ❑Outstanding Balance Due:
I Cj
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructiou'Supervisor License(CSL)
LQN �(,1 License Number Expiration ate
Name of CSL Holder
List CSL'I'ype(see below) kA
(R�3 In-c "type Description
No.and Street
I 4�V\ O U Unrestricted(Buildings u to 35,000 cu.ft.)
h 1') ).J R Restricted I&2 Family Dwelling
City/fo o,State,ZIP M Mason
ry
RC 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) IoO 3
L M 1-1 2f9� HIC Registrar xpiratioA D,to
HIC�o4 pxn Name o F C erlmnt Name
No.and Street r Email address
Cit o n,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
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matter ela ive to work autho ' ed by this building permit applicati .
Print Owner's N,, c(Flectroni i t 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.
_ U►1' USs y U /
Prim wner's or Authorized Agent's N e(F onic Signature) Dote
NOf ES:
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
CITY OF 3:U-El,i, :1SSACHUSETTS
41) BUILDING DEPAMLENT
[10 WASHLNGTON STREET, 3� FLOOR
TaL. (978) 745-9595
IU3tHERLEY DIUSCOLL F-tx(978) 740-9944
&LAY0,,1 'MaNLAS ST.PIEAM
DIRECTOR OP PUBLIC PttOPEATY/BLILDLN(;COJL\nSSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
(n accordance with the sixth edition of the State Building Code, 730 OAR section It 1.5
Debris, mid the provisions of tNIGL c 40, s 54;
Building Permit 11 this work shall is issued with the condition that the debris resulting from
I 11, S I50A. be disposed of in a properly licensed waste disposal facility as defined by tmGL c
The debris will be transported by:
(nama ut'I tler)
'['he debris will be disposed of in
r
(nnm�c o'ty•
—_� (adU�k.5 of taerl4 y)
ut permit.rvant
Luc
r
n-
r
CITY OF S:U EM, NLNSSACHL:SETTS
t BUILDING DEPART\LENT
110 W.AsHLNGTON STREET, 3ca FLOOR
TEy (978) 745-9595
FAx(978) 740.9846
KI\IBERLFY DRISCOLL
MAYOR THOMAS ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUUXfDIIG CO\L\HSSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
N 3111C(Batiues.vQrganizatiom/'Individ_u alil): 01. 711,t LL q
Address:
City/State/Zip: Phoned: / (1�7__?
Are you an employer!Check the appropriate box: 'type of project(required):
L❑ I am a employer with 4. am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ I ran a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y. ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation mid its
required.] officers have exercised their
10.❑ Electrical repairs or additions
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.[No workers'
sump.insurance required.] I3.❑ Other
-Any applica fl Ilwt checks but AI must also rill out the section below showing their worketi compensadun policy in tbrmation.
'I lomeuwm",rho submit this affidnvit indicating they arc doing all work and then him outsidecontmetors most submit a new atfidavll indicating such.
K\muactors thus check this box must attached an addiliuruil sheet showing the noire of the sub-conincton and their workers'comp.policy information.
I aza an employer that Is provfdhrK workers'coarpensadon insurancefor my earplayees. Below Is the policy and fob rile
information.
Insurance Company Name:
Policy A or Self-ins. Lie. 0: Expiration Date:
Jub 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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 undlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to$230.00 a day against the violator. lie advised that a copy of this statement may be, forwarded to the Office of
Investigations of the DIA For insurance coverage verification.
I do hereby certify under the Pulfis and penalties of perfary that the infor✓natlmr provided above ix true and correcL
Date:
Officiul rue only. Do not write in this area,to be completed by city or lows officiuL
City nr Tuwn: __,_.. . .__ PcrmiUl.lccnxc q ,
Issuing Authority(circle uric):
I. Board of Ilcallh 2.Building Dupartincnt 3.C'ilylruwn Clerk 4. Electrical Iuspectur 5. Plumbing inspector
6.Other
Contact Penns: -... phone a:_
]
53
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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
W Reconstruction ❑ Alteration
❑ Demolition 1 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: 1 80a Federal Street
Name of Record Owner: Peter Parnacsa & Alexa Ogno
Description of Work Proposed:
1. Install new storm windows in the color white
2. Rebuild front chimney in-kind. Design, size, color, and mortar joint size to match the existing chimney.
3. In-kind repair to the front door.
4. Repaint front steps to match the existing.
5. Repaint back steps to match the existing.
Dated: May 7, 2014 SALEM HISTORICAL COMMISSION
By: C
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.
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