36-38 SUMMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
A/.
,i Board of Building Regulations and Standards
1y, Massachusetts State Building Code, 780 CMR, 7"'edition
Building Permit Application 'ro Construct, Repair, Renovate Or Demolish
Otte- rrTn•r famdv Divellin1;
/This Sec on For Official Use Only
Building Permit mbeer/rr/: Date Applied: /
Signature: /(tirt�° 3 f
Building Commissioner/Inspe t dings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [,at Area(sq It) Frontage(11)
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 Zone'? Municipal❑ On site disposal system ❑
Public[3 Private❑ al Check if yes❑ F p y
SECTION 2: PROPERTY OWNERSHIP'
2.y'Ownert of R`l�ord:
o vy?,( 36-38..�vir wlnrf� S�1
Name p rint) J Address for Service:
XSi nature releephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building I Owner-Occupied �t Repairs(s) bk Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building S I. Building Permit Fee:S 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
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S k-00, 0z) ❑ paid in Full ❑Outstanding Balance Due:
X
�7a�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(ESL)
License Number Expiration Dale
Name W CSI.-I loldef
List CSL I)'pe(see below)
'I\PC I Description
Address
ll l'nreslricteJ a l0 35,1100 Cu. Ft.)
itRestricted 1&2 Family Dweilin
Signature bt Masonry Only
RC' Residential Routing Coverin
I elephone \VS Rcsidemiol Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I, ,as Owner or Authorized Agent hereby declare
that the s ents and informati n on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
bYJ
a�
Print Name 3/ //�
Signature of n r or Authorized Ag nt Date
Signed u er the pains andpenalties ofperjury)
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(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 and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations I IO.R6 and 110.115. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabilable room count
Number of fircplaces 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 he substituted lbr"Total Project Cost"
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CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPAM. PENT
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HOMEOWNER LICE.NSB EXEMPTION
Plea""I
Date
Job Location —3 SUM M = S
Home Owner Adders.
Home Omen.Telephone —
Present Mailing Adiao
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who.does not possess a licm",provided that the owner acts as supervisor.
DE INMON OP HOMEOWNER
Persons) who owns a parcel of brand on which he/she resider or intends to reside, on
which there is, or is intended to bs, a one or two timily dwelling, attached or 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 bylaws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and r uirements and that he/she
will comply with said procedures and "0 rements.
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HOMEOWNERS SIGNAMME
,APPROVAL OF BUILDING LISP CTOR
See other side for state code