16 HARDY ST - BUILDING INSPECTION (4) %0• rev
t
The Commonwealth of Massachusetts CI"fY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Fmnily Dwelling
This Section For Official Use.Only
Building Permit Number: Date Applied:: 4 IA-E.A 3
Building Official(Print Nam . ignature-
SECTION 1:SITE INFORMATION
1.1 Property\Address: 1.2 Assessors Map& Parcel Numbers
�1�N a -&,
1.1 a Is this in accepted st et?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(I1)
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❑ y"
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑ p p
SECTION 2: PROPERTYOWNERSHIPt
2.1 Owner'of Record:
�ne Prin`t)\ City,State,"LIP
1 l
4 u• 3t.,6$1 A, GR�n.c�s.
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 1 Existing Buildingfe I Owner-Occupied N( Repairs(s) IK Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ 1 Other ❑ Specify:
Brief Description of Proposed Work'. n to v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
d. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6. Tutal Project Cost: $ so-C D 11 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
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5.1 Cottstructiott Supervisor License(CSL)
License Number Expiration Date
Nance of CSL Holder
List CSL"type(see below)
No. and Street Type , Description ,
U Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityllown,Stine,ZIP M Masonry
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(IIIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name -
No.and Street Email address
City/Town,State,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 15Z.§ 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'
I, as Owner of the subject property, hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nine(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby,attest under the pains and penalties of perjury that all of the information
conta e in this application is true and Yaccurate to the best of my knowledge and understanding.
Print Owner's or Autlwrized Agent's Name(Electronic Signature) Date
NOTES:
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 nut have access to the arbitration
program or guaranty fund under M.G.L. c. I42A.Other important information on the HIC Program can be found at
w Ww.mass.Huy02a Information on the Construction Supervisor License can be found at cvww.mass.�,ov/dps
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. Total Project Square Footage"may be substituted for``rota) Project Cost"
CITY OF sm Ens
PUBUC PROPERTY
DEPARTMENT
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ML •lot&s'tzrw�w
HOttitEOWNER LICLNSY E.XI.MyTIOcV
PW" Prime
Dose q
lob Loeadott \(o
Home Oscar Address 1
Home Owvor Telepboa s
Present Mailing Address
Do curial esempdon of"Homeowners"was extended to include owasr occupied
dwellihire who
of e ace
Units a teas sad to allowr such homeoween to eagaga as individual rot
hire who.does sot possess a lieensa provided that the owner seta as suparvisor.
DEFQYMON OF HCAa0WNBA
pawn(s) who owns a paneal of Lad an which WAS resides or Iaterads to reside. an
which than iti or Is intended to be, a one or two r&Wly dwsUln& attached of detached
strucawm accessory to such uss mWOr rum squcnu,es. A pama who constructs more
rhea one home is a two yeatperiod shall not bs considered a homeowner. Such
"homeowner"shall submit to the Building OQlciA an a forts acceptable to the Building
Oflleial, that he/she be responsible rot all such worst performed under the Building
Permit
The undasiped "homeowner'usumes responsibility rot complianes with the State
Buildings Code and other applicable bynlaws and reluladcn&
The undersiSned"homeowner certirses that hdshe undentands rho City of Salem
Buildinl Department minimum inspection procedure and requirements and that hdrhe
vile comply with said procedures and r tiremenu.
FiOS1EOSVNERS SIGMA rL-U
.APPROVAL OF 9U/LDIVG INSPECTOR -
�cd other fide for State code
CITY OF S.U..E1\I, N-LuSACHUSETTS
BI:ILDL\G DEP:NR'I1lENT
+ 120 WASHLNGTON STREET, 3' FLOOR
T EL (978) 745-9595
Fix(978) 740-9846
Kl,%{BERI.EY DRISCOLL
T
;i�g,;YOR �iObtAS ST.PIERRfi
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CO\12,1ISSIONER
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 wi II be transported by:
y o C- 4r-ac 4M(
(name of hauler)
The debris will be disposed of in :(name of facility)
_�O r
ddress of facility)
signature of permit applicant
5A
date
v��co T
�9TA
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
❑O 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:
Replace the existing rear portico using same materials, design, and paint colors.
Non-applicability clue to work being in-kind replacement.
Dated: September 26, 2013 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.