22 SUMMIT AVE - BUILDING INSPECTION (6) 1� The Commonwealth of Massachusetts
— - Board of Building Regulations and Standards CITY
m 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
\vn One-or Two-Fumily Dwelling
T ection For Official U my
Building Permit Number: Date plied: +`
Signature: -
Buildi missmner/Inspe for Idings Date
S C ION 1: SITE INFORNIATION
1.1 Property Ads '��1 1.2 Assessors Map& Parcel Numbers
L I 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 11) Frontage(11)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check ifyes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner f R cord: e
JY)1
Name(Print) Addr ss fo Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all t apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Othe'E, ❑ Specify:
Brief Description of Proposed Work:
i
6PYj1ev1 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ $ 1. Building Permit Fee: S Indicate how fee is determined:
4524 ❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: (X
5. Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
• I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
� I I�,ro J �� L eeme u I spiratir I to
I
N f L-1 er rn� ist CSL fype(see below)
V -r Description
res
U Unrestricted(up to 35.000 Cu. Ft.
R Restricted 1&2 Family Dwellin
a are M Masonry Only
RC Residential Roofing Covering
Telep one WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home 1 ent ntra
1-1 or HIC R•�istr n Nu t t o y Registratio ber'
Addr s
Expiration pate
ib a Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CON TOR APPLIES FOR BUILDING 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.
rr
Signature of Owner Date
CTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
1 �—
rint ame
ig re o wner or Authorized Agent Date
(Signed undt the pains and penalties ofperjury)
NOTES:
I. An O ner 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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I O.RS, 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"
11-MAR-00 02:51PN FRO►+ws Depot 2686 +9787401402 T-892 P-001/007 F-051
HOME IMPROVEMENT CONTRA[;l'
PLEASE READ THIS
Sold,Ydrmsaaa auu r,u,47,..3 Ly:
' THD At-Home Sotvices,Inc.
p +' Dasloa �e _- dlWa T1+c Home Depo[Asusr,MServices.
�s7J�J— - 345A Greenwood SrzeM Unit 2,Wacesrer.MA 01607
Toll T-,,,a(EW)657-5187:Fax f508)756-8823
Federal ID#75-2698460;ML'Lie#C a7b39. Coop LicH 16427
D.emeh Pivmlwr it ,y. ,' cr L:e w- ^ ��-`t �'fa improvement �/T tractor Re6.R 126893
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Home Address: �,. State Zip
(If different from installation Address) : al t (sal iq tQi^I� `� ' Lary-,
&y.�j►Address(to reoelve ptnjeet comttumicauons and «updates)
.
W1 DO NOT wish to recdve any madoemag emoods from � t��m too sir;naxllatiop address,agrees to iwy.
Yhniert L tfjtrntatlon- undersigned("Casmme>'),r�OW°�at fie pr..r+�saY• for the installation(-hlstallabon")of
and THD At-Home Services,lnc.(-"hoe Home DepoC'1 agrees to fucma4 de, and arinn� Una Contact by dl:s
,D,mv+ers,lt 4e. * ml an the below and M the referenced Spec SheeKs), all of�wA hymn and Orders(collectively,
rele. nee.along With sAY epplica6fe bbox SLppiGmtliram4 Aprs.r.�+SummnS
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lloofieg Suiios .ndows lamlagon
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❑Roet-ms Sidlog. windows- LIM18tiOn $.
❑Gunves/Corns [tentr7 Do®❑
ag S;d;ng j Windows Imulaom $ .I✓(V` - `�' _-,
QGutmrs/Cer'a5 OlinoYDoors [L� W
PAbd m 75%DRoaYdCorar Amomutdm puw otlhiemmraa. Total Contract Amount s c)-- ] 8 s
N1suePWdr�asma9notdrposlt®eboaoneaHedol&eCommrtAnta�. . .
--CPisenmer ag thbG tmaledt� P�—cOmpleaan-of the wmlcfor i ch'Prodnet.Cos[oma wi¢-execut�a ComPleGon.Cerdlicam
(onc for each Prod=us defined by an individual Spec Sheet)end pay any balance doe. As applicable,each Customer under this
Contract agrees m be joindY and_severdly obligated and liable be moder.
The Honor Depot aeserves Me right to issue a change Order or terminate this Contract or any individual pmdurx(s)included herein.at
its discretion,if The Home Depot or its antltod d seraiee provider .rieterorim`s that it cantor perform its obligations due r a structural
problem with dre home,em o onrremnl hazards such as mold.asbestos or lead point,other safety concerns,pricing errors m because
work regaimd to complete the job was not included in the ConiracL'/ _
q_ ( �7 m h did as part of his Contract sets forth the,total
Co teem Snmroand The Payment d for the # .-Fs=����(as applicable)-
Conuact-moon[and payments requited for the deposits and"fora[payments y
NOTICE TO CUSTOMER a Certificate(now:
Ytnr are raptled to n t� Ceero'C tmr"n wary vrthc Coutraat ai raw deew true aiL'6 Do mhtSh�)ben v e�work m Idol 1.'atnl„ct
there is arm Cottgrletutr 1cod a for each UsUd Product as defined by ltdMdrml 9pee _is complete- the costs of materials,labor,expenses
In the suite of termination of dtia Camhaet,C.rstou"agreea` to�ProvOdtH toeegb the door of termioaton, lus any other
and services provided by The Home Depot or Aadmrized SetvieeUNT
amounts set forth m this Agreement or allowed ender applfeahie law. THE HOME DEPOT MAY W1TL 0 A FROM THE DEPOSIT! PAYMENT OR OTHER PAYMENTS MA0E, WT0 S
OWED
Y:IMITIN 'TIM HHOME DEP Tim HOME OT'$OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
and understands that this Agreement is the enure agreement between Customer
.�re.-eL and Androrizsdan: Cusamer agrees an discussions and agreements,either
and The Home D¢Tpi with regard m the Products and Insmllahan services and be edporoamended except by a writing signed
oral or wrine%re said Productsoand Installation.�s A agrees and t smmer read,understands,voluntarily accepts the
by Costo r The Ho Depot.
terms of and received a of this AgmntmL
Sub fey-
A - s �c
sales Consultant's S' at Date
now 'gr' " a� •{ ? �G
Telephone No. 5
X.
Customer's Signature Date Sales Consultant License No. tas appucabta)
CANC16f,LATTON: CUSTOMER MAY CANCEL THIS
ACRILEPTT WITHODT PENALTY OR OBLIGATION
BY DELIVERING WATf°fEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGRISWNT. THE
STATE GEn%Pj A4j!%rr ATTAVRED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICfi:pDDIT10NALTfiRMS AND COND17'lONS ARE ATATED ON Tlifi RFVMSfi S[DE AND ARE PART OF 7tffi CONTRACT
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lizaxovich
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' ° I! 15 Garland St, Lynn, NA 01902
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o "Qi' 3 CCourse Date: 12/22/09 - ExamDate: . 12/22/09
Expiration Date: 12/22/2019
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Certificate Number R I 18867-09-010
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Trainer: Date:- z
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a a n n Massachusetts - Department of Public S tfch
7.� A Board of Buildin?, Regulations and Stank ,'ds
Construction Supervisor Specialty License _
License: CS St- 100e29 I
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a .-`� l SIARHEI 4LIZAROVICH-
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1 av o i LYNN, MA 61902
2- 10
ni a aI Expiration: 7/I/2012
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C'um...csi, er Tom: 100e29
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Siarhei Alizarovich
Allsson Insulation&Window Company
Has successfully completed the
National Fiber Cellulose Application Training Course
this lOt" ay of_December 2009.
"l Cw" v� { NFN
. 5tophe,L.White, ational Fiber
FIBER
Director
or o(saies
Not vafid unless embossed