88 SUMMER ST - BUILDING INSPECTION O� The Commonwealth of Massachusetts CITY
�y Board of Building Regulations and Standards
�y Massachusetts State Building Code,780 CMR,T"edition OF SALEM
Revised January
,. Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or TWo-Fa Dwelling
) Wldmg;PermuNutnber 'it % 'i" ;��te p iig3t f
Signature ` � 1
�Uldtng Gomi�rssronet�1n� etor o Biul � � ��_�. >� at¢:
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
k b---f, n -e-/Q 61.1 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(ft)
1.5 Building Setbacks(It)
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❑
SIjC�1®V P1 11 O TESfI�P.
2.1 Ownerr f Record:
Name(Print) ° Address for Service:
f 2pis'— S-3 / Z
Signature Telephone
SEG TIbN 3 DE' CRIPTItIN; F TOSID,�VR =(c�teck`all that apP1Y)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
" f r Ve— T IGL
SECTION 4:ES I STS: '
Estimated Costs:
Item Labor and Materials Only
1.Building $ 1 BuildmgP,etnt Fee $ :Indicate how-fee is.determined-.
2.Electrical $ Stitidard Cuytfd�n Appkcanon Fee-
4 l ofa3'f ro�ect gs4' te(n 6)x yl-Pher x
3.Plumbing $
.
4.Mechanical (HVAC)
5.Mechanical (Fire
Suppression) 3atal{1 FseS>�&
C)teek h]o �lredk Atrropnt Cash Amount:
6.Total Project Cost: $ hl�f�[/j ❑pazd in�ull ❑,Outstanding$alance Due:
�� Gaya
3�rb
5.I Licensed Construction Supervisor(CSL)
M C P (- License Number Expiration Date
Name of CSL-Holder- v
��P.VLt L,-"00 �--U`T° S List CSL Type(see below)
Address l r 0 .°. s�P, .+�rf a ,,,r b;i. _'nhl tion,.
a Z'sd
/r� l U -Unrestricted u to 35,000 Cu.Ft.
'''r " '` ��' R Restricted 1&.2 Family Dwelling
Signature M Masonry Only
7 S 3 RC Residential Roofing Covering
Telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Regt'stere H e I tprovement Contract IC) �D 3-1 ti
1( M , > . '� � I "mac,. GG
HIC Corany,Name or C ReA nt ne ^ Registration Number
J Theo • P - , ,�[ 1/ �
—�—
L
2&f':n3 Expiration Date
Sig P nature / Telephone
SECII4N 6 WQRTSERS?COMP$1SgI191�INIIRANCF AFFIDAVIT(M G:G,: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...........❑
"SECfIO)vT.7s del# UT!)id,1t1ACION; BF1C .� y �4'TF a
OVY}VER'S A—GEENT.6 CONFyR�SCT DR`i1PPP S FOR BIII
/l `I / C p/Q G!!I as Owner of the subject property hereby
authorize f44 to act on my behalf, in all matters
relative to work authorized by this building permit application. D /
!f C
Si nature of Owner - ate
-OW
'TN f 3IEfsLARAtION "
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.
L
Print Name
Signature of Owber or Authorized Agent ` Date
Si ed under[he sins and enalties -
x`- * g _
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 importantinformation on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"