6 SUMMIT AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
� \ Board of Building Regulations and Standards CITY
1 Massachusetts State Building Code, 780 CMR, 70' edition OF SALEM
Revised January
Building Permit Application To Couslruct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-F ily Dwelling
Thi S ,tion or OfHciallJse Only
Building Permit Numbe Dto plied:.
Signature: Zog
1
Building Commissioner/I eetor of Bii IdM-Al Date,a
TSECTIO SIT— INFORMATION
1.1 ProperwtAddr , t 1.2 Assessors Map& Parcel Numbers
L l a Is this an accepted street?yes no Map Number Parcel Number
CA 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2 PROPERTY'Of YNERSHIPt
2.1 Owner'of Record: '
u yl�}1, "� �. r- CC ( ( Yi
N Pnn Address for Service:
`7 � g- 7Lts -
Si ure Telephone
SECTION 3: DESCKIPITOMOF PROPOSED`-WORKz(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) j?4 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: k e P L e C
1 r4- PC (CL, 1Vx,&
SECTION,4:ESTTMA CED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials .OfficiaFUse Only-
1.Building $ a G O C c p 1. �Butidmg Peimt Fee: $ - Indicate how fee is determined:
0 Standard,City/Town Application'Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FfVAC) $ 'List:'
5. Mechanical (Five $ '
Suppression) Total'AII.F,ees: $4
6 (^ C , P e Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑-Outstanding Balance Due:
SECTION 5 C SERVICES
5.1 Licensed Construction Supervisor(CSL)
1 t r(`F Ol s Lo , ^C�-r " License/Number Expiration Date
Name of CSL-Holder List CSL Type(see below) U
2 !� M r,4 �w ,T e Description
Address U Unrestricted(up to 35,000 Cu.Ft.
()4 L,1 -/-r e/ e:t C9 J. R Restricted 1&2 Family Dwelling
Si •e , _ JJ lL,(n M Maso Only
�/Y RC Residential Roofing Covering
Telephone WS Residential Window and Siding
ry G., •-� r� („� /1 x y, SF Residential Solid Fuel BurningAppliance Installation
/ `4 / G D Residential Demolition
5.2 R1s j red Home Improvement Gontrpgtor(HIC)
r( 'z' ✓1 w '^C( n I I C /
HIC Company Name or HIC Reg trant Registration Number
Addres Ly
-4' v ! �'}}("" 7 7! I�2 —Z Expiration Date
} Signature ( .�{ �, Telephone
t xxx ,
SECTION 6:WORKERS''COMAENSATION+INSURANCE AFFIDAVIT(MG.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...........A`
SECTION 7a: OWNER AUTHORIZATION TO 13E'COMPLE`TED WHEN
OWNER'S AGENT OR CONTRACT OICAPPLIES FUR<BiJILDING PERMIT
I, 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.
0/, . O/"/D
Si up6 of Owner Date
SECTION41b: OWNER'OR AUTHORIZED AGENTDECLARATION
1, + as Owner or Authorized Agent hereby declare
that ih statements and information on the foregoing application are true and accurate,to the best of my knowledge and
be] .
(y 7FFi A', CEC6�2 SkI
Print
a, ��p 0�� OG .DI-/o
Signatur of Owner or Authorized Agent Date
(Signed under the pains and enalties of e
-
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 0.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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i CITY OF SiUMN12 NaSSACHUSETTS
BUILDING DEPARTNMNT
130 W�sHINGTON STREET, 3" FLOOR
TEL (978) 745-9595
PAX(978) 740-9846
KINMERLHY DRISCOLL
MAYOR TT o&w ST.PmRm
DtRECrOR OF Pt:HLIc PROPERTY/BunmiNG co%L%assiONER
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;
1� 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 will be transport
®ed by:
E, '5w : -j�'c f j
(name of hauler)
The debris will be disposed of in :
G KOO C) < <r&ci/
(name of facili6)
(� [ 30 G`OV�Cwlll Ma-
(address of facility)
signature of permit applicant
date
debris rdw
CITY OF SOU E2N1, 2%LkSSACHUSETTS
• BUILDING DEPARTMENT
' 120 WASHINGTON STREET, 3'o FLOOR
TEL. (978)74S-9S95
FAX(978) 740-9846
K MBERLEY DRISCOLL
MAYOR THObus ST.PIERRa
DIRECTOR OF PUBLiC PROPERTY/BL'QmtG CO�L�ItSStONER
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
Applicant information gleage PrintLegibly
Name(BusinessiOrganization/individual): L"' I'^� e 4, fit';/ l° ✓ 4,
Address: �� I i VVI f iti / � 4 ��✓
City/State/Zip: h 0 �-L"! .+ Phone #: `;" `>` '] ,l L/
Are you an employer.'Cheek the appropriate boa:
Type of project(raryired):
1.0 1 am a employer with 4. [] 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.® 1 am a sole proprietor ar partner- listed on the attached sheeL t 7. Remodeling
ship and have no employers These sub-contractors have S. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9. Building addition
[No workers'comp. insurance 5. (] We are it corporation and its
required.] officers have exercised their 10.[] Electrical repairs or additions
3.[] 1 am a homeowner doing all work right of exemption per MGL 1 I.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
•Any applicant thW chocks box A I must also rill gut the section bciow showing their worker• w4m lion policy infomntiom
s lInmeownes who submit this striders irdiadng they am doing all wodt and thin hire outside co m etm most submit a now affidavit indicating such.
:Cummcton that cheek this box must anaehod an additional shed showing the.taane of one ab owttnetar and eheir wodma'comp,policy infotmadw.
I am an employer that is providing workers'coaspensalon Insurance for my employeex Below Is the policy and Job site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 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 may be forwarded to the Office of
InvLstigations of the DIA for insurance coverage verification.
I do hereby eerd, �under thepains and a es ofperJ,uu tha the information provided above Is true and correct
Sign; -, + f/IZ,,"/ Date- �� / V
Phone#:
OJJlciai use only. Do not write In this area,to be completed by city or town aJJlcisd
City or Town: - Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cily/Towa Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person Phone