61 SUMMER ST - BUILDING INSPECTION ` � a
i The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repa novate Or Demolish a
One-or Two-Family ellin
t� This Section Orr Official Vc Only
\I Building Permit Number: p Date A lied:
Buildina Official 0Pint Name) v Si to
SECTION 1:SftE INFORMATION
1.1 Proper Address: 12 Assessors Map&Parcel Numbers
�t I ,J vn,rn r..
L 1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f1) Frontage(tl)
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❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerro Record:
�yo��
Name(Print) City,State,ZIP
Cal s( M62 st W-V7 -r�3
No.and Street Telenhone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Numbber of Units Other ❑ Specify:
Brief Description ofPro�°sed W rkZ: e. 2 I ' f2 .e r'1oe ' uq
' P.J
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 'a d,00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityffown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ ^' /- �
4.Mechanical (HVAC) $ List: t/
5.Mechanical (Fire Su $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7--p ❑Paid in Full ❑Outstanding Balance Due:
4�cz
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Yo3�� G-/ -/z
/7104 V LicefscNumber Expiration Date
Name of CSL Ho er
List CSL Type(see be ow) U
o.and Street n' �L Type Description
2 e✓rr e /e'�/ ,2 �,� U Unrestricted(Buildings to 35,000 cu.ft.
M Restricted M2 FamilyDwellin
City(I'owq State. IP
asomy
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address raA D Demolition
5.2 Registered Home improvement Contractor(MC)
//� /G6a�3 0EWLonD
-13
AJ� �-�tj 7✓g/Y�'n �O HIC Registration Number Expiration Date
HIC Fomy Nameogry HI�Reeis�ant.�lame ✓ r G a
l� I Pr.('ra,yi( 1-y � � 3 CG✓ ( �lhag. lo/s.
N and Street Email address
►gZ�r�e 44I - 0 2 ld/ 7 y/—GTE GS:py
6 /fown.State.ZIP Tel hone
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
I.as Owner of the subject orooerty.herebv authorize Tn
to act
�on my behalf,in all matters relative to work authorized by this/building permit placation.
HFAP-t�--r t1r;od L /3 -
Print Owner's Name(Electronic Simoture) Date
SECTION 7b:OWNER',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.
Print Owner'sA Authorized Aeent's Name(Electronic Si_epanue) Daze
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(MC)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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or 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/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
aCITY OF S�IXx4 ,1%yWSkCHUSETTSBt:tWING DEPARTNIENT
l'_'O WASHINGTON STREET,3'a FLOOR TEL (978)74S-9595
FAX(978)740-9846
KIMBEni EY DRISCOLL
MAYOR THOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BtiIIALNG CO\LHISSIONER
Workers' Compensation Insurance Affidavit: BuildersiContractors/ElectriciaiWP[umbers
Applicant Information A / Please Print Leeibly
Name(9asinessorganization/Individuaall): A /
Address' / 9,� 4�C
City/State/Zip: i2,0-1err ,Ak ®�-/Tl Phone!i: 7Y/ —C }.)- — C.SS 5`
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general connector and 1 6. ❑New construction
employces(fu11 and/or part-time).* have hired the s&-conractors
2. 1 am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp-insurance 9. ❑Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 1011 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I-❑Plumbing repairs or additions
myself.[Pro workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' MCI Other
comp-insurance required.]
•Any applicapt That checks bat sl most also fin mi the sections below showing their worker'cennpenmm policy information
'I lamemm em who submit this aHrdsvil indicating[hey ore doing all work and then him ouleide cenoeetora poet atthmh a ntav alruhvit irtdit>tdittg ate
:Centnectem that cheek this box rout madtod an additional sheet showing tlx:rune of theaubcorremr and their wodoer'tamp.policy information.
/am an employer that Im providing workers'compensation lnsaraecefor my employees. Below Is the polity and fob site
inlarma ion.
Insurance Company Name:
Policy#or Self-ins.Lie.#: { Expiration Date:
Job Site Address: �. f✓hr m P / City/State/Zip: Pm
Attach a copy of the workers'compensation Polley declaration page(showhig the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day against the violator- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains a�ndd perraUles of perjury that the information provided above a ct.true and corre
Siemn[re�J�VSti/i.�'�� Date L — �/— /t/
Phone
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: Permitfl.fceme#
Issuing Authority(circle one):
1.Board of Ileallh 2.Building Department 3.Cityrfown Clerk 4.Mectriel Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i CITY OF S.0 Ebl, 1NL-kss kcHusETTS
• BUIL.DLNG DEPIRTImN'T
120 W.ASHLNGTON STREET, r FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KLJtBERLEY DRISCOL.L
MAYOR THomAs ST.PLER&E
DIRECTOR OF PUBLIC PROPERLY/BUILDING COSZLLSSLONER
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 wilt be transported by:
J;F7
(name ofhauter)
The debris will be disposed of in :
(name of facility)
SHI C�9 Alf--
(add ss of facility)
;016re of permit applicant
date
debrivt7:dce
0