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183R FEDERAL ST - BUILDING INSPECTION V The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards lomomw Massachusetts State Building Code, 780 CMR, Pa edition Building Dept \ Building Permit Application To Construct. Repair, Renovate Or Demolish a OKVSMWNS Jl One- or Tiro-Fwnth Dwelling This Section For Official Use Only Building Permit Number: Date Applied: r 0 Signature: N 2 Building stoner/Inspector of Buildings DaN SECTION 1:SITE INFORMATION L 1 P rt AP res 1.2 Assessors Map i Parcel Numbers �s - — 1.1 a Is this an acce ted street''yes n0 Map Number Parcel Numbe: _ - s 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ana(sq R) Frontage IR) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Wooer Supply:(M.G.I.c.40,154) 1.7 Flood Zone Infornulloo: 1.8 Sewage Dbposol System: Public O Private 0 Zorta: _ Outside Flood Zones? Municipal 0 On site diapossl system 0 Cheek if s0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:. Ari /� / 7 Name(Print Address for Service: 97� 7Vr-- ZS� Ivan" Telephone SECTION): DESCRIPTION OF PROPOSED WORK'(cheek AB that Apply) New Constitution O Existing Building 0 Owner-Occupied O Repsire(s) 0 1 Alterstion(s) 0 Addition 0 Demolition O 1 Accessory Bldg.0 Number of Units Other 0 Speciry: / Brief Description of Proposed Work': - SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: OMCI&I Use Only Item Labor and Materials I. Building f �j€W 1. Building Permit Fee: f Indicate how fee is determined: 0 Standard Ciry/Town Application Fee 2 Electrical f 0 Total Project Cost'(Item 6)a multiplier x ) Plumbing f 2. Other Fees: f a. Mechanical IHVAC) f List: S Mechanical (Fire S Total All Fees: f Suppression) ,,�� Check No. _Check Amount: Cash Amounl:_ 6 Total Project Cost: S CYw ❑Paid in Full 0 Oulmandmg Balance Due' SECTION S: CONSTRUCTION SERVICES 9.1 Licensed Constructlon uper0sor(CSL) 4Z5 d o C LiccnX VYmbaf E p411On 0iiii, yyae of E-SL- 110§111111, < ! Liar CSL Type lxY llrlowl A,Wrrss C?! (io RD Description [Restilentiall restricted u to}7,000 Cu. Ft stricted 1h2 FamilyDwelling Sianamre > son only sidential Roofing Covering Telephone idential Window and Sidra idential Solid Fuel Burning Appliance Insulation Demolwon 3.2 R Ist r`� Horm Imp ore et Contractor(HIC) 79 t Ll Y F>t HIC C mpanp N s or l�I�RegistrantReglstrauon Numbn Address, Extinuitsh Date Signanue Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL I ISC(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 Artached7 Yes..........i& No...........O SECTION 7m:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. A-., Z' as Owner of the subject property hereby authorize 'IW,4 to act on my behalf,in all matters relative to work au rized by-this ipplication. n of Owner Dote SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION r✓Si �!�� S as Owner or Authorized Agent hereby declare that the sutcmenu and information on the foregoing application are true and accurate, to the best of my knowledge and beh.u. Prim S 2- 2- s Gt7 Signawe of Ownd or Authorized Agent Date (Signed under the pouris and penalties of 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 I HIC)Program),will so 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 110 R6 and 110 R3,respectively. 2. When substantial work is planned,provide the information below Total floors area(Sq. Fl.) (including garage, finished basemenVanics,decks or porch) Gross living area ISq. Ft.) Habitable room count ,Number of fireplaces Vumber of bedrooms Number of bathrooms Number of halfDaths Type of heating system Number of decks/parches Typeof cooling system Enclo%cd Open s "Tool Pro)ect Square Footage"may he wh.timteJ for Total Prolccr Co%i" CITY OF S.1I.ENI, jAkSSACHUSETTS B1:aMLNG DEPARTIE.�1T I'_O WAsmmi;TON STREET, )era FLOOR TEL (978) 74S.959S FAX(978) 7249&W KINIBEALEY DRISCOLl MAYORT11obW S7.P[Elutt DIRECTOR OFPLBLICPROPERTY/lIUM NIGCONMUSSIONER Workers' Compensation Insurance Alildavit: Builders/Contractors/ElectriciansdPlumbers A r licant Information 1 Please PrintLegibly V31T1t(Busin 0rpannrationlndtvtdual): ' G Address: CJ d l e-W-C-eq °7 7� City/State/Zip: Ial Phone M:�r' �57} - P.q5 5y Are you as employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a cmploya with 4. 0 1 am a general contractor and 1 employees(full and/or part-time)." have hired the sucontractors S. ❑New construction 2.0 1 am a sole proprietor ar panne- listed on the attached sheet: 7. 0 Remodeling , sub-contractors and have no employees These sucontractors have B. 0 Demolition working for me in any capacily. %workers'comp.insurance. 9. 0 Building addition INo workers'camp f0 insurance S. We are a corporation and its10.0 Electrical repairs a additiorq required.i 0171cers have exercised their, J.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs at additions myself.(N'o workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs insurance required.)t employees.(No workers' 13.0 OOur comp insurance required.) •Any apphcma thw choc4 boa At mere aW fin old The tactics bbs ce showing trade workm'ccnpnmlice policy infumradoa 't hmseuwmta who subunit this adhirvb indiainp they am doing all work and thus him austidd eemmmwe mild-hine a new arndavd Indicating ruck ('.xnnaun nut check phis box muet anmhad an additional ahem thawing the nes a orna aukeomnanwa sd dub wcshem'camp.policy inraamitiaa. f am aei etnp/oyer their is providing workers'compensadion insarev jot cry employeex. Mew Is!keRwhy,afiefM s/ks informal" 7 ? A Inwrance Company Name:- �j(�� 'c Gry Sip C/i/ 5. Policy M or Sell-ins. Lie. #:: � /dq ygd D- p a Expiration Date: z z-21./ )fib Site Address: r 25 � ' 1 !- jma, S 7/ City/SlatNZip: ¢� OIZZ, ! .%crotch a copy of the workers'compensation pokey deelqrstbn page(shawl n Iha 1/ policy number and expiration date} 1 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a k fine up to S1.500.00 amUor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDEA and a fire of up to S250.00 a day against the violator. its advi.wd that a copy of this statement may be furwarded to the Office of Invcahgmiura ul'the n1A for insurance coverage v.:riticution, i do hereby rrrlijy under the Pa/as an Me G ojperfury that the information provided above is/rut and contra OJJicim/use oet/y. Do cot owrite in this urea,to be,wapietd by city or/own n/flitiat - City or town: PermiN.lcense e � 1%suing.Nuhorify (circle fine): 1. Ruard of MAIN 2. Ruilding Depardmend I Cityfrown Clerk 4. Electrical fn m speclor 5. Plumbing Inspector 6. Other L--ilacl Person: -__ -. Phone e' 02-16-'10 12:39 FROM- T-915 P002/009 F-665 ' ® sowmimrn= GRANITE STATE INSURANCE COMPANY 0092241-00 WC 007-42-6452 13102 - _ -..._.._._- 013-66-0309-00 PARSON N LDERS INC o ^ Oil"Oil" Member Companies DI 1 0 R WINONONA ST }� LOQ9 ABODY, MA 01960-0000 •„AR American International Group 111FF�� EXECUTIVE OFFICES: 70 PINE STREET. NEW PORK N.Y. 10270 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE-WC990610 - - - LDAMA Ui#- PHIL RICHARD & ASSOCIATES INS INC WORKERS COMPENSATION AND EMPLOYERS 491 MAPLE ST LIABILITY POLICY INFORMATION PAGE STE 102 p S MA 0 2 -0000 CORPORATION RENE AL 0 82668 2 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF REM 1. OF THE INFORMATION PAGE-WC990610 M02 POLICYPEIaDe 12.e1 AM Manifold 11m9 e1 tte lnauredh memngaddrea FROM 03/17/09 To 03/17/10 1710,111 A. Workers Compensation Insuralma: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA IL Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item aA The limits of our liability under Part Two are: Bodily Injury by Accident$ 100,000 each BCCIda1fT Bodily Injury by DIBea9e S 600.000 polity Iirtlit Bodily Injury by Disease $ 100,000 own employe C. Other States Insurance: Part Three of the policy applies to the states, H any, listed here: SEE ENDORSEMENT - WC200306A D. This Policy includes these - SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE -WC990612 ITEM A The premium for this policy will be determined by our Manuals of Rules, Classifications.Retain and Rating PlaM All Information required below is subject to variRretlon and change by audit ESamaMd Telal Raw Per a3nmned ClasMlievic" Cad*Nam", RamYarallan side OF Ra. Premium O.Annual❑3 Yost muted n ©Annual ❑3 Taw SEE EXTENSION OF ITEM G OF THE INFORMATION PAGE —WC7756 TAXES/ASSESSMENTS/SURCHARGES $188 EXPENSE CANIMANT 10CM WHERE APPLICABLE BV STA7E) 18 MA MINIMUM PREMIUM SSOO MA TOTAL FSTIMATID PREMIUM S3. 323 II IMisatia below,inlaNm adiuslmenn of Pramium atoll be made: Swni•Annutly Danndy Montldy bzp=PREMIUM 03/24/09 ASSIGNED RISK 66 Maus Date - IaWngottiva AWWriMd Represantet" WC 00 N 01 M67 faav a 04AB) ' R r CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT owy w/ ,1,11:: X I F1 !-KM I'•11 9t 120 WA I VAit IIXG;(1,V SmfT •S.0 1'%1, bt.Ni\t III it 1ia'1 :. 978J43A595 •1:.t X:778.740-9846 Construction Debris Disposal Affldavit I (required fur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit H _ 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 I11. S 150A. The debris will be transported by: 9 I (lame of hauler) The debris will be disposed of in 5� C (nuneu acuity) (address of I'aciluy) %ignature of immit applicant due I,a„i.,lt„m PEARSON BLUDERS Genamt Contractor - - Warren A. Pearson 150 R.Winona St. Phone&Fax 978-535-6555 W.Peabody,MA 01960 Cell 978-758-2938 Massachusetts-Departmeni of Public Safety, Board of Building Regulations and Standards C8aIs4CuCYlpa:Supervisor License. IiCense3.Cs ' 40995 NARRE E4RSON 1.50R 01 8 0- V11 PFABO Expiration: 4/1212011 Tr#: f3734 rp . Gf�te: emW Board of Building Rega,a nsan�Standards•:- HOME tNIPROVEMENT CONTRA CTO.�t Registry 107999 x r Est�jltahbn - 1112010 Tr# 72 C yy C� 4w. - V` arten Pearson r k . . .150R Wtnolia S. ' o �1 �rnra; 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 -J4 Alteration ❑ Demolition ❑ 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- 193 Rear#9 Federal Street Name of Record Owner: John & Monica Zisa Description of Work Proposed: Replacement ofsix windows in violation on second and third floor with Brosco, wood, .single glaze, double hung, true divided light windows to match existing windows on house, painted to match existing Replacement of roof with 3-tab, Certainteed Seal King roof with option,for color to be either Star White to match existing, or to be black or charcoal grey. Dated: _February 4, 2010 SALEM HISTORICAL COMMISSION By. 1%611 Gl/ 11 The homeowner has the option not to commence the work (unless it relates to resolving an Itstaing 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.