16 HARDY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
t Board of Building Regulations and Standards
�— Massachusetts State Building Code,780 CMR S
Revised dM Marar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
Tbis Section For Office Use 013
Building permit untkaer . Date Applied:
t )3riildiing Official-(PriotName) 'i, . . St�attve.
I SECTION 1;STTE INFORMATION]
M1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted s eet?yes ✓ no Map Number Parcel Number r
13 Zoning Information: 1.4 Property Dimensions: ; k
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard p
Re gaited Provided Required Provided Required Provided es,+
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record*
•\ Yf:. d
Dame ' t) City,State,ZIP'
, \\ \ i' 9l E- lglk ."/ r 5 ,Ge1Ya-�
I ( n {"1 ®��-'e1,t,. --- Telephone Email Address
No.and Street
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work!-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1, Building Permit Fee:$ Indicate how fee is determined:
1.Building $
o Standard City/Town Application.Fee
2.Electrical $ p Total project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees; $
4.Mechanical (fWAC) $ List,
5.Mechanical (Fine $ Total All Fees:$
Suppression
Check No: Cheek Amount: Cash Amount:
6.Total Project Cost: $ 9)- ❑paid 11
Full ❑Outstanding Balance Due:
I-D t l 9 Mp l L tgV
SECnOP15; CONSTRUCTION SIERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Tree Description
U I Unrestricted(Buildings up to 35,000 Co.It.
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masomy
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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone,
c SEI:ITTON 6,WORKERS'COMPENSATION H MJRANCE AFFIDAVIT OLG.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...........❑
SECTIOnf 7a:OWNER AUT1115RUNTION TO BE COMPLETED WHEN
QYMR'S AGENT QR COMRACTOR APPLX$FOR I#T7Il ING PEMM
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.
i
Print Owner's Name(Electronic Signature) Date
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 accurate to the best of my knowledge and understanding.
M04Ycrsooutho' d Agent's Name(Elec nic Signature) VDate
Ss
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
mtilvw.mass. ovg (oca Information on the Construction Supervisor License can be found at www.mass.eov/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 halUbaths
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"
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ua WA=atSnaer,r'A,00t
$DAR YZWACCLL FA8P74D.M 6
DMUSaPIEW
i aFp= CMQwaT/jUMMDi CawMM
Construction Debris Disposo►/Affidavit
(required forall demolition andrenovatfon worky
In accvr&m with the sha edow of the State&fig�,7Wa^Section 11L5 DeM
and the provttbns of INGL 010,S S4;Sul ft ftrn*N &hmred with the
con�r►tath the debris from this ww*sM®be deed of I..
Ikewd
waste depw*bdlity as defhW by M A.GL c lily S 156 Pr+ Y
The debris win be transported by:
sera ��ti��
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of lity)
tgnature of applicant
Date
a
QTY OF SALEM, MASSACHUSE TTSBUILDINGDEPARTMENT'120WASFRNGTONSTREET,3"DFLOOR
IEL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.nERRE
DIRECTOR OF PUBLICPROPERTY/BUA.DING OCASUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date_ID Z ►A
Job Location U,
Home Owner Address
Present Mailing Address
The current exemption 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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(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-familydwelling,
elkn attached or g, 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
Permit.
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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
M.
Salem Historical Commission
120WASHINGTON 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: Derby Street
Address of Property: 16 Hardy Street
Name of Record Owner: Deborah Prentice
Description of Work Proposed:
In-kind replacement ofdamaged wood clapboards and trim.
Paint entire house to match existing colors.
There will be no changes to the color, material, design, location or outward appearance of the house. Non-
applicable due to being in-kind repainting and replacement.
Dated: October 11, 2016 SALEM HISTORICAL COMMISSION
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 of four-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
Buildings (or any other necessary permits or approvals)prior to commencing work.