65 SUMMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR 7" edition
J Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commission /Inspector of Buildings Date 9
SECTION 1: SITE INFORMATION
'-'6'
perty Address: 1.2 Assessors Map&Parcel Numbers
1.1 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 ft) Frontage(lt)
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 O�yn 'of Record:
�( y ` owelL`� 6 s Sye n wt e(L 5T
/ Name(Print) Address for Service:
W -9;xex ;xz--1/- 5zye
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: T)G'GK
Brief Description of Proposed Work2: R["UP eX i9�-tt•C 8 t X l g r CK Re P(Gc, W i-l\
f.Iew 8' X t6' �ecLk
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 4111
4.Mechanical (HVAC) $ List: /� o U
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
ft)ad) A66eoc�z
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0102g I 3 7s�IZ
'SoL-,v\ Q-,0—IytCC% License Number Expirati nDate
Nam f CCSS,LM Holder CQ't ' s pry List CSL Type(see below) J
�ZrqAd s ,X PJ
Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si ature o C M Masonry Only
C11 'Z 31 S 116 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5._Registered}tome Improvement Contractor(HIC) t 4o /
HIC Company Name of HIC Regrstrant Na c Registration Number
3oruAmohte4itARcl 1vDs�� m �X( Ltl 21I 'Loll
r VA ` CL'& Expiration Date
Si rem V 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
I, /�d✓j G. tvQ,v S as Owner of the subject property hereby
authorize 0�-�oz 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
1, ��Q�(C\ ,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.
30LIn.
Print Na a /`/ ho
SignaW of Owner or A horized Agent Datd/
(Signed under the pains and penalties of perjury)
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 780 CMR Regulations I I0.R6 and 110.R5,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.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hall7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S��I_E:tii, TNLkSSACHUSETTS
• BL'ILDIING DEPARTMENT
• p 130 WASHIINGTON STREET, 3-FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERI.EY DRISCOLL
MAYOR THows ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BL'ILDL\G CO%MSSIONER
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
rdebris
Qwill be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
v
(address of facility)
,
signature kofperm applicant
date
JcbrisalT.Ja:
CITY OE Sm &m. A-kss.kCF{t,'SETTS
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Workers' Compensatlost Insurance AMdarit: guilders/ContractorWElectrlclansiPlumben
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Name Iau,fne+aOrgasusnefvlfvhvratnll:
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Address:
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1.0 13012 entpbyer with s. Q I ar s)penaal coatraeror&"1 R ❑Now construction
cfnpleyem(IWl aadrar pan-time),e have hired the sub.eomncses
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(No worker'comp insurance f. Q Wo or•cerpesadas and is I0.0 Electrical rapaire or additiar
rcgtrifoal °tikes haw osaelaed tick
f.Clm m 1 a a homeowner doing ad work ri&of esanpd m pw ING. 11.(:1Plm ubing repain or addkbro
myself.(No worker'comp C. IS2.11(4),and ices bare its 12.❑Reorre isa
insurance required.(► cmpisyceo (No"°char 13 Q Otbar
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insurance Company Name!
onlicy 0 or Self•ins. Lio.N' Expiration Dote:-
job Site Adthse City/Staunzip:
.\note a cep of the workers'compensation polity dak nibs pep(shelving tki polky number sad osple atbo date}
Failure to sccurt corenp so requited under Section 25A of MGL a. 152 can lead to the impookln ofcriminal penalties of
Ane up to S 1.500.00 and/or one-year irnprisomnetK ar well as civil penalties is do form of a STOP WORK ORDER and a flas
arup to S350.00.s day ayoinsn the violator. I'd adri..*A rhNa cupy of Ibis sratrahaa maybe forwarded to the OIMce of
Ins.erfg:rrius ul'ilia nlA farinsurancocoverage rvrilk-A a
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city or futrn: Prrmit/Llcenr 1__ _ _
h,uing.\W burly leircla unel'
1. Ituard utllralik 2. nudding Wparimcne 1. CYlrtrown Clerk 1. flectrical Impector 1. Plumbing In.peeter
6.Ulher _
i L..nlatl rcnon: _ -. Phone I'
Board of Building.Regulatiefis ;;,tS1WNhk.
HOME IMPROVEMENT CONTRACTOR "
Registration.: 14647G
Expiration:. 4/27/2011 Tr# 282209
Typo: Individual
JOHN REPUCCI
JOHN REPUCCI '
30 CAMPMEETING 110 11'.-
TGPSFIELD,MA01983'--' - AdmiuistnNm; ?
Niassachusetts - Departmcnt (if Public Safcty
t Board of Building Regulations and Standards:,
Construction SupervisorLicense
License: CS 90281
Restricted to: .00. A7 ,�
JOHN REPUCCI
30 CAMPMEETING RD
TOPSFIELD, MA 019831-
Expiratan: 3/420.72'' 1.yryk
('„nm:nefunrr Ty{: 20pt3 .
Deck-$5,760
➢ 2' X 8' Pressure-Treated Frame �f K/M, S'" ` e 5
➢ 5/4 x 6 Azek decking choice of colors plug screw system 5�ot �jft�/
➢ Railways railing system.(white) with base and cap
➢ Skirt and slats around base of deck made of PVC
➢ One small gate for access under deck
➢ Old existing deck dismantled and removed
➢ Work area will be left in a neat and orderly fashion each night
➢ Permit included
Payments are as follows with checks made out to John Repucci
➢ 1st upon acceptance $1,920
➢ 2nd when material arrives and start of project $1,920
➢ 3rd upon completion $1,920
Respectfully submitted / L44 `1'
rllf
Signature r��
Date of Acceptance Mal �O J 0
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