53 INTERVALE RD - BUILDING INSPECTION (4) QThe Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. T"edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tivo-Fmrtih Duelling
ton For Official Use O y
Building Permit Nu er: Date A plied:
Signature: ng /
Building Commis s n r/Inspector of Buildin ate
SECTION l: SI NFORMATION
1.1 Pro erty Addreps. 1.2�ssy,;�t�iap_& Parcel NZ'erSC,0
3IPn$�t-Va�e .SS
I.I a Is this an accepted street'?yes V no Ma_ p Number Parcel Number
1. Zoning Information: I IA�POro�y Dimensions: 7b1
a 'S
Zoning 1 District Proposed Use Lot Area(sq it) Frontage III)
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:
/ Zone: _ Outside Flood gone? Municipal WOn site disposal system ❑
Public❑ Private 0 Check if esLg
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner o Recor`d•/ .' �� / ✓ r1 ._ r' �j� ����U
Name(Print) Address for Service:
Signature Teleph6nc
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Rf Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': od `
Gt/ �� ^�- rS C.7 ASS�Oh Uh ✓�/ �
V
SECTION 4: ESTIMATED CONSTRUCTION COSTS (�
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ I. Building Permit Fee: S Indicate now fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechamcai (Fire S Total All Fees: 5
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S _0 ,Q t' 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Ngme of CSL- Hplder
� List CSL Type(see below)
Address T —Description
U Unrestriclyd u to 35,000 Cu. Ft.)
Signature R Restricted I&2 Famd Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 PP ES FOR BUILDING PERMIT
1, R as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this buildin pe tt application.
l
—�Z/ /_0
S, ns�f Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, , 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.
Print Name
Signature of Owner or Authorized Agent - Date
(Signed under the pains and penalties of perjury
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unreontractor
(not registered in the Home Improvement Contractor(HIC)Program), will not have access to thn
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC P
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110. ,,ograjmand
d 11ectively.2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemttics, 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/porchType of cooling system Enclosed pen
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEMI, MASSACHUSETTS
a a
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 ExT. 380
FAx: 978-740-9846
Thomas J. St.Pierre
Director of Public Property
Zoning Enforcement Officer
Section 116.0
Demolition of Structures
Structures over fifty(50) tears old must have approval of the
Salem Historical Society
UTU fTY DISCONNECTIONS REOUIRED
Authorized Azent Date of Disconnection
Water: 41� _
(see attached requirements)
Electrical: v �
Fire: CIE '?p2/0
Sewer: �
Salem Historical Commission:
Dig Safe Number: 00 9V 00(v85
Pest Control: Uc z4oa 1111 oq
t
"*D
OCUMENTATION OF ALL THE ABOVE!MUST BE ATTACHED BEFORE PERMIT CAN
BE ISSUED***
Fee for Demolition: $5.00 for application plus$2.00 per 100 square fk gross area, minimum$15.00
Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX(978) 740-0404
WAIVER OF THE DEMOLITION DELAY ORDINANCE
It is hereby certified that the Salem Historical Commission has waived the Demolition Delay Ordinance for the
proposed demolition as described below, as per the requirements set forth in the Historic District's Act (M.G.L.
Ch. 40C) and the Salem Historic Districts Ordinance.
Address of Property: 53 Intervale Road
Name of Record Owner: Mathew W. Nichols
Description of Demolition Work Proposed:
Demolition of house.
Dated: 3/19/09 SALEP I HISTORICAL COMMISSION
By:
THIS IS NOT A DEMOLITION PERMIT. Please be sure to tain the appropriate permits from the Inspector
of Buildings (or any other necessary permits or approvals) prior to commencing work.