16 SUMMIT AVE - BUILDING INSPECTION Cr, I2.R3t( 2�"
INSPEC RECEIV
The Commonwealth of Massachusetts 11S ~ S VICES
Board of Building Regulations and Standards f&T'Y�OA'
Massachusetts State Building Code, 780 CMR Revised,Vhir 241
fib .
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Data Applied-.
. Building 017icial(Print Name). - Signature Dat
SECTION I:SITE INFORMATION'
J t P roped,Address: ^ e 1.2 Assessors Map&Parcel Numbers
I.la yes Is this an accepted stree nc Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq I)) Frontage(It)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ al Check if es❑ P y
SECTION2: PROPERTYOWNERSH10
2.1 Owneft pf Rccord�
7j„a ,l or,N,2s SfOre+- �ol )ems
�me(Print) // City,State,ZIP
j / lirS ±,
rtm�7J �Y7l� Kr-,si1P/ S �Or'e'1r�� r✓1Rt �.cD
o and Sucet Telephone ErndVAAddr s
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Acczssory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=: 00
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item - Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Tgwn Application Fee
2. Electrical $ ❑Total Project Cost?(item 6)x multiplier x
3. Plumbing $ 1%9therFees: S /�
4.Mcchanical (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
6.'rotal Project Cost: •S 19N ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ` t
U_
��17W - Z— 4���S License Number Es ru' nUale
Name ufCSL Holder
( ._./- List CSL'fype(see below)
o) �jt�Q�lT✓2P / ✓L� p Description
No.and Street I - — ._
a� ✓eV-S / V I Unrescted 12 Fr(Buildings tip to Dwelling
cu. 11.
' (/I �2L6/ �� R Restricted )&?Famil Dwellin
Cilylrown,S� M Masonry
�p L; �QJ t�'ypq�J•LO�'VI RC RootingCoin Wind
�a WS Window andd Siding
Solid Fuel Doming Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 9 3
/ r H /IC Registration Number :. ration Date
HIC Cum :my Na, o HIC Registrant NNa
y�o.an Street �'Jit Email address
/der M of rrr r/l
City/Town,State,ZIP 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°
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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 'tt this a I' ion is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's ,n (Electronic Signature) Date
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(111C)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www mass eov'oca Information on the Construction Supervisor License can be found at www.mass.sov�lJns .
2. When substantial work is planned,provide the information below•.
'total fluor area(sq. R.) 't .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
;lumber of bathrooms Number of h:dt7baths
Type of heating system Number of decks/porches
'rypeofcoolingsystem Enclosed Open_
1. "Total Project Square Footage"may be substituted for"Futal Project Cost"
Y° CITY OF S:U.E.NI, %'-Wsika-iusETTs
C� 3 BULLDLNr,DEP.IRTJIE\T
i t i 120 %V.iSHL4GTON STREET, 3"FLOOR
TEL (978) 745-9505
P.u.�t(978) 740-9846
KI\tBERL.EY DRISCOLL ,
a N AYOR Trio&LuST.PIERaa
DIRECTOR OF PUBLIC PROPERTY/BULL.Dr1'G CO\LMISSIONER
1Ynrkers' Compensation Insurance alffidavit: Du]lders/Contractors/E]ectrlcians/Plumbers
Applicant Information T ♦ Please Print Legibly
�hIInC(fluaitxssUrganiraui.iminJilidual): /�Agr ,N ei Lej hP �,� t Try d //[.py.,Uol�°��
Address: lfi` Zo/'s/reefs h + P
Cily/State/Zip: y, ,Zee�f _/y I/� Phone
Are you sea employer?Check the appropriate boa: rJ3.0
project(required):
1.❑ Ism a employer with 4• 1 am a general contractor and Iew construction
employees(full and/or pan-time).• have hired the sub-contractors
2.I-1 am a sole proprietor or partner- listed on the attached sheet Iemodeling
.hip and have no employees These sub-contractors have emolition
working for me in any capacity. workers'camp.insurance. ilding addition
I No workers'comp.insurance- 5. ❑ We are a corporation and ita
required.] officers have exercised their ctrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption par M a 11.0mbing repairs or additions
myself.(No workers'sump. c. 152, 010),and we have no of repairs
insurance required.) I employees.[No workers, er
comp.insurance required.]
•nny applia:un Tito ducks hue II must also fill uul nw sestiao below showing their workam'mmpetmdon policy iufunmat(on.
'Ihun.uwnsr who whmit Oda amttnvit Indicating they am doing all work and than him outside ronlnrtors into,submit a new aJ17Javit indi atiny such
:('ummctum that Amlt Ibis box mml attached an addidutml aline,showing the mama of the aubtonuaclem and thdr warkers'sump.policy infumution.
I unt an emplulver that Is providing,verkers'compearatlon husurunee for my employees. Below is the pulley and Job rile
infurutution.
Insurance Company Name: _
Policy/7 or Srif-illy. Lic./h Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the worlters'compensation pulley declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A ofblGL c. 152 can lead to the imposition of criminal penalties Fife
Fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against Flit violator. Ile advised that a copy of this statement may be forwarded to the 017ica of
Inves,igmiuns ul'the MA for insurance coverage vcriticatiun.
/era hereby certify raider the puhu uud penahles of perjury that the hifursnullarr provided above is true uud c orrect.
Phone 4:
D%fidal use only. Do not write he thiv area,to be complet<d by city ur lorvn ojJhiaL
City nr't'Fiwn: _ ,_ __ Permiul.tcense q
Issuing Autltnrity(circle one): 7— �illl
I. liourd of llealth L. I)uihlln>;I)epartntvtu {,fityf(uwn Clerk 1. F.leetriul Ltepectur 5. P6. Other
otact I'ersoo: Phone 1t:
�I �� ruzayp 1 ii
Office of Consumer. &Busidess Regula[iou
t E IMPROVEMENT CONTRACTtSR' Type.
• qe,g�istratwn 178197
piration . 312V2016 DBA
ED BRUENJES FINE CARPENTRY&REMODELING
t ib 4 4
ED BRUENJES
101 BRADSTREET AVE.
I
DANVERS,MA 01923 Undersecretary �I
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction C Supervisor
License: CS-044-1,
```-e., i, o,.
EDGAR BRUENJO
101 BRADSTREETA
DANVERS MA 61
�2.lI-j(#- Expiration
commissioner 07/01/2016
i
QTY OF SALEM, MASSACHUSE M
BuLDING DEPARTMENT
._. 120 WASHINGTON STREET,3RD FLOOR
7tL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR T7-omm ST.PmRm
DIRECTOR OF PUBLICPROPERTY/BU1W1NG 0018IISSIOMR
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
c-
(name of hauler
The debris will be disposed of in:
-------------
(name of facility)
(address of facility)
Signature of a 'cant
Date