25 SUMMIT AVE - BUILDING INSPECTION r
I The Commonwealth of Massachusetts
I Board ut'Building Regulations and Standards CITY
�� S ' ) Massachusetts State Building Code, 780 C'MR, 7'"edition OF SALEM
QyA Revuwd Juiroon•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. va6v
One-or Two-Family Dwelling
This Section For Olricid Use Only
Building Permit Number: Date Applied: ,l
Signature: z22,�J
Ruildhs Cu tuned Inspector of Buildings this
SECTION 1:SITE INFORMATION
I Pipe Add fl 1. Assessors Map d1 Panel Numbers
I.I a Ibs this an acre ted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Ld Area(sq 11) Frontage(11)
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 Sewsga Disposal System:
Public O Private O Zane' — CheckOutsid Flood if es0 Zone' Municipal O �'
On site disposal stem O
Check
SECTION 2: PROPERTY OWNERSHIP'
neCrt aNS n Ct uL 0)
Nye(Print) Address ror Service:
`�/, yea., 27L
si
N
Dgnature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
ew Construction O Existing Building O Owner-Occupied O Repairs(') O Alteration(s) O Addition O
emolition O Accessory Bldg.❑ Number of Unit_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U Only
Labor and Materials Use n
y
I. Building S 1 I. Building Permit Fee: S Indicate how fee is determined:
�. Electrical S O Standard City/Town Application Fee
O Total Project Cost(Item 6).a multiplier x
1. Plumbing S 2. Other Fen: S
J6.
. Mechanical (HVAC) S List:_-
T—
. Mechanical lFire S
u ression Total All Fees. f
7�O Check No. _Check Amount: Cash Amount:
Total Project
Cost..
S ❑paid in Full 0 Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number lxpiration I}ate
Name of CSI.- Iluldcr I.ist CSL fype(see below)
r Descriewion
Address U l7nresuicteJ u w 33.DOD Cu. FI-
R Restricted Idl2 Family Dwelling
Signature M M. (MI
RC Residential Raclin Coverin
felephrne WS Residential window and SiJin
SF Residerxlal Solid Fuel Burin A liance Installaliun
D Residential Demolition
5.2 Reghtered Nome Improvement Contractor(HIC)
I IIC Company Name ar HIC Registrant Name Registrations Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.f M(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 ..........0 No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNER'S AGENT OR CONTRACTOR//APPLIES FOR BUILDING PERMIT
1 e&J2�/ j. /�f<P�9/ as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relaptive to work authorized by this building permit application.
signature ofowner Dale
SECTION 76:OWNERI OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of(honer or Authorized Agent Date
E
under the sins and (ties of 'u
NOTES:
Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC)Program),will_W have access to the arbitration
gram or guaranty fund under M.G.L.c. 112A.Other important information on the HIC Program and
nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R5,respectively.
2. en substantial work is planned,provide the information below:
oors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
iving area(Sq.Ft.) Habitable room count
of fireplaces Number of bedrooms
of bathrooms Number of half/baths
heating system Number of decks/porches
cooling system Enclosed Apen
tal Project Square Foolage"may be substituted for"Total Project Cost'
CITY OF S.UE.Li
PUBLIC PROPERTY
DEPART1NiENT
Ill 1O�LN N�',Y
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TM 9'.a•7+S-9S" 9 F.%x 979.7469"
HOMEOWNER LICENSE EXEMPTION
Pleue Print
Date
Job Location S
Home Owner Address J/ 7
Home Owner Telephone
Present Mailing Address l/ 7
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside. on
which there is, or is intended to be, a one or two family dwelling6 attached or detached
structures accessory to such use and/or farm structures. A person who constructs mom
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE 6 r�� eCcf�
.APPROVAL OF SUILDI.YG INSPECTOR
See other side for state code
CITY OF SALEM
SL
PUBLIC PROPRERTY
` DEPART'NIENT
..,I . 'u IJ' U \�111\t•. ".11 il.l r � \.\II \I, )1.\.\\I .. I .I'I .
III- 'r'w'1;.•�;r � I \r. �'x 'a;• .SL,
Construction Debris Disposal Aliidavit
(required lbr all demolition and renovation work)
In accordance ith the sixth edition of the Slatc Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal lacifity as defined by MGL c
l t 1, S 150A.
The dchris will he transported by:
(name of hauler)
I he debris will be disposed of in
(nalnr of facility)
(address ,I'lacdity)
H L;IIalllle of permit applicant
9Aa/id
date