71 SUMMER ST - BUILDING INSPECTION g'
OThe Commonwealth of Massachusetts
i Board of Building Regulations and Standardsja *kvmmwma
own of
Massachusetts State Building Code, 780 CMR, 7'"editioning Dept
Building Permit Application To Construct, Repair, Renovate Or Demoli
One- or Ttto-Famil•Duelling �
This SectiopIfor Official se Only
Building Permit Number: qq pile ppl'
Signature: — 3d l 09
Building Commissioner/Ins or of B Idin ate
SECTIO E INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7f (VTmbr .CT (AC&n /Ys�t
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 fl) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
K. InAlf- fV 7�
Name(Print) Address for Service:
978 71/ fig"- ! 2yrS0z6
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work': /7Z f f-n 1ti. n c, AA-W
Fr nbn,—CA
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ O CJOO , I. Building Permit Fee: f 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 (HVAC) S List:
g. Mechanicai (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6, Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /z�O Q r
r CS 86 Z � ,
License Number Expiration Date
NSmc of CSL-Helder List CSL Type Uce below)
A � 7 .f7i"Y -fir CA/.'�2A
AJJr• C�'�.S'9—G`'2 M N o 30 36 T Description
U Unrestricted u to 35.000 Cu. Ft.)
R Restricted I&2 FamilyDwelling
F
M Mason Only
RC Residential Roofin Coverin WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R�e$gi��tered Home Improvement Contractor(HIC) /6 3y0 7
l�vHc RWD 20"t !lam nFutiG
HIC Compan Name or HIC Registrant Name Registration Number
�D 7 L/w-cR^fZ I Alit A R I'�6�p L(
Addrcss� t�
4 POC/O Z;S Expiration Date
Signa Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.0 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........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(. 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:OWNEW OR AUTHORIZED AGENT DECLARATION
76alf.
as Owner or Authorized Agent hereby declare
rmation on the foregoing application are true and accurate,to the best of my knowledge and
i„
Signature of OwQFor A oriz d Agent Date
7MU'r the ains and penalties of perjury)
NOTES:
er who obtains a building permit to do his/her own work•or an owner who hires an unregistered contractor
istered in the Home Improvement Contractor(HIC)Program), will yf have access to the arbitration
or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
bstantial work is planned,provide the information below:
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage" may he substituted for"Total Project Cost"
CITY OF S,. .EM, ,LkSSACHUSETTS
BUIIDLNG DEPARTMENT
l'_O WASHINGTON STREET, lea FLOOR
TEL (978) 745-9595
c FAX(978) 740-98"
K1SlBFRi FY DRISCOLL .
MAYORTHOMAS ST.PlEM
DIRECTOR OF PLBLIC PROPERTY/BUILDING CO%MUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
Applicant Information ,/ Please Print Legibly
Nadne (Busirw orstni:atiomindsvidual): 11bwz---/ ( RMD fAAd /LFMot7ELl !r %DI N 16"Irt- )
Address is C AAf- 2.O ,4
City/State/Zip: G/ tT,f/t N•H -%703 6 Phone#: g7,P If f>22J—
Are you an employer'Check the appropriate box. Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1
��}mployees(full and/or part-time).• have hired the sub-conuacron 6. ❑New construction
,Yy/1 am a state proprietor or partner- listed on the attached sheet 1 7. remodeling
6 ship and have no employees These wbcontracton have g. molition
workingfor me in an capacity. workers'comp.insurita
Y P tY• ❑ building addition
required.]
ired.]workers' comp. insurance S. ❑ We aft:a corhave
exercised
and its 10.❑Electrical repairs or additions
required.) officers have exeteixd their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152.§1(4),and we have no 12.❑ Roof repairs
insurance required.)t cmployeco. LNo workers' 13.0Other
comp. insurance required.)
-Any appiitaA this checks has el must alas fill out the Mlim below showing their workm'compensariwt policy information.
'I1, m owrsxs who submit this aflloLvil indicting they are doing all work and than hire onside can mmm meet submit anew antdavit indicaun,suck
:C.naracon that.hack this box must alrichd an additioratl sheen showing do name of rho sub-comnector a and their wohera'comp.polity,informadm,
l am an employer that 2r pravidlnR workers'rompemadon Insarance for my employees. Below Is the palley and Job rile
information.
Insurance Company Name: t</-lk1d-S10Ld- IA S t L*. Ce it(!F, ty �Cr�r Jed•-2 Cz- o.�
Folicy N or Self-ins. Lic. N: 6C R r O)(a yZR Expiration Date: f Z46,016
Job Site Address: 7l LX0l t*t(—,1 .57— 14t-r•s A City/State Zip: Zo
,mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
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 S 1.500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Incesugationa of the DIA for insurance coverage veri tication.
/do hereby eerdi/y under the purns mad penuldes ujperJury that the informalloa provided above is true and correct
n•r t Ir ' Data! �24�"f
Phan d: JOY O 73�
iOffriciul use only. Do nor write in this area,ro be cuntpleted by t-4y or tawn offlrral
City or Tuwn: _ Yermit/Llceme# _
1%suing Aulhorily (circle one)!
1. Board of llealth 2. Building Department 3. City/fo%n Clerk 4. Electrical Inspector 5.:Plumbing Inspector
6. Other
C,nuact Person: _. .. -- -- Phone N•
CITY OF SALEM
r+ PUBLIC PRc)PRERTY
DEPARTMENT
1 A ir.,.., .>::11 r • i V I \1. \I
III '4;-'1'"N 0 1 �X 'i's V: 'li J,.
Construction Debris Disposal Affidavit
(required lirr ❑II demolition and renovation wurk)
In accordance \%itli the sixth edition of the State Building Code, 780 CNIR section If L5
Debris, and the provisions of:b1GL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall be disposed of in it pruperly licensed waste disposal facility as defined by MGL c
11I. S 150A.
The dchris will be transported by: .
T
UIJmc ul hullary
The Jcbris will be disposed ofin : 37D M—to DL,-V--S1?�1
�1, , (IIJIpCulIJC1111V)
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alm p:nnit .ylphcJnt
�JIC
�As u a� lraaoadcrrKll6
Board of Building Regulatio�t9 and Standards
Construction Supervisor License }:
Limit; : CS 86200
Expiration:,802009 Trill 13027 :
Restrit:tl on: O0
JOHN E HOWELL `t
107 HARANTIS LAKE R�� -�-- .'•
CHESTER.NH 03036
Commissioner
� 1
�'/ie 7°aomvmo�uoea.� a�✓�,aa,ac�waeQ2
Board of Building Regulations and Standards
lug HOME IMPROVEMENT CONTRACTOR
Registration: 163407
Expiration: 6/16/2011 Tr# 285498
Type: DBA
HOWELL AND SONS REMODELING
JOHN HOWELL
107 HARANTIS LAKE RD
CHESTER, NH 03036 Administrator