31 SUMMIT AVE - BUILDING INSPECTION (2) 71 3a�
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only,
Building Permit Number: Date Applied:,-: O -
Building Otficial(Print Name). Signature Date -
SECTION Io-SITEINFORMATION
1.1 Proper1 ., (ty Address: ^ ,, W 1.2 Assessors Map&Parcel Numbers
�
1.1 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(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewageosal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal eon site disposal system ❑
Check if yes❑
SECTION2. PROPERTY OWNERS HIPt
2.1 Owner'of Recor`�t�)
SI�UmvK l I/2V�orM4^- L/GhUGLf\ AAA,
N)me(Print) City,State,ZIP
F-d- 5D9--q'CZ- 3'Tf f
No.and Stree' •t Telephone Email Address
SECTION 3: DESCRIPT N OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Cl I Repairs(s) ❑ Alteration(s) Ol Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_y Other ❑ Specity:
Brief Description of Proposed Work': —'Al S — Al2U/ k C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 06O 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee -
2. Electrical $ 66 d ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ l® J66) 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. iNfechanical (Fire $
Su ression) Total All Fees:$
// Check No. - Check Amount: Cash Amount:
6. Total Project Cost: S 3 b� ❑Paid in Full ❑Outstanding Balance Due:
3,
r S
SECTION 5: CONSTRUCTION SERVICES
5.1 Constru)uction Supervisor License(CSL) GS l O—!1
Jps G�0. S1\on tn)�C( License Number E.epimvon e
Name of SL Holder V
list CSL"type(see below)
No. an
nd Sveet Type Description
C/4hlrGy S� — 0 f�Z3 U Unrestricted(((Buildings u to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP M I'vlasonry
RC Reeling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name -
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION:INSURANCE AFFIDAVIT(M.G.LG c.152.g 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
t4 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:OWNERI OR AUTHORIZED AGENT DECLARATION
By ei 'ng my name below,I h eby a test under the pains and penalties of perjury that all of the information
c taine ip this app�eatior s R e and accurate to the best of my knowledge and understanding.
CC\\�J
Print O er's r Authorized Agent's Name(Elecronic Signature) Date
NOTES:
I. V=wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
egistered in the Home Improvement Contractor(FIIC)Program),will not have access to the arbitration
gram or guaranty fund under bLG.L. c. 142A. Other important information on the HIC Program can be found at
w.mass.1 ov'oca Information on the Construction Supervisor License can be found at www•.mas.�>ov:!dPS
2. When substantial work is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"
CITY OF S:1I.E:�rt, lI.-1SS:ICHUSE-nS
e BtiunLNG DEPA&j-.%lE2%iT
130 WASH04GTON STREET.3"FLOOR
TEL (978) 745-9595
F.mX(978) 740.98•]6
KI.%BERL SY DRISCOLL IH06G�SST.PIERRS
MAYOR
DIRECTOR Of PCBLIC PROPERTY/Ot:QDL`IG COMMISSIONER
Workers' Compensation Insurance AITidavit: Builders/Contratitors/Electr{cians/Plumbers
alanlicant In(ormatton Please Print Legibly
varnC(ntaincss,Organiratierulndividual): .SK-0 oy, .�3 De U. Iop
Address: U- 7?61`f fti0
CilylStatc/Zip: o,,ve,r AtLl� PhoneN: � e`9rZ7 35��
AyClant
un employer?Check the appropriate box: Type of project(required):
I. a eat to er with 4• I am a general contractor and{P Y b. ❑ ew construction
ployees(full and/or part-time).• have bin J the subcontractors
2. m a sole proprietor or partner- listed on the attached sheet.t 7• Remodeling
ship and have no employees These subcontractors have a. Cl Demolition
workingfor me in an capacity. workers'comp.insurance. 9
. Y P tY• ❑ Building addition
(No workers'comp.insurance 5.'[1 We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL I I•❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4y,and we have no 12.❑ Roof repairs
insurance required.]t employees.Lino workers' 13.❑Other
comp:insurance requimd•]
;Any upplic:ue that chicks box*I mart also rill out the seetitso below showing their workers'compensation policy inlonmutom
I l.vneuwmvs who submit this ffildavie indicating they am doing all work and then hIro u6lsida cantmaan mtul submit sinew amdavil indicting ruck
k:ummcton thot chssk this box most attached an addiaund sheer showing the name of the sub•contmctom and their workers'comp.policy information.
I an an eurplayer that h pruvldlirR workers'compensarlon h juronce for my employees: Below/s the polley and fah slfe
injanrrutiom
Insurance Company Name:
Policy 4 or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/Statr/2lip:
Attach a copy of the workers'compensation policy declaration papa(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ot'XIGL c. 152 can lead to the imposition of criminal penalties of a-
nine up to S1,500.00 untVor one-year imprisonment,as well as civil penalties in the Conn of a STOP WORK ORDER and a line
Of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the office of
Investigations ul'dte DIA for insurance coverage veriliealiun.
I du hereby c•err rider di pal and p les uj erfary that the befurnrmlent provided above is true and carreea
i I r S T/� 2cs!
Date,
P , ,t. 5D - <TG Z— 3 7/
OJJicla/use ly Oat not write in/like area,to be completed by city ur town n=Plunar
CitynrTasvPermIt/T.Iccnse,9lasuing.\ut1, rity(circle one):1. Duurd of Ilcaith 2. Iluilding Department 3.Cilytrown Clerk 4. Electr
6.0ilter
Contact I'crsnn: Ottona 8:
[
a
CITY OF SiXLEm. NL-kSSACHL'SETTS
BI;imDx DEPARTMENTlx
N 120 WASHINGTON STREET, 3w FLOOR
T EL (978) 745-9595
F.jx(978) 740-9846
KI%CBERLEY DRISCOLL
,BEY D THo.%w ST.Ptam
DIRECTOR OF PUBLIC PROPERTY/BUILDING C0\11MISSIONER
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 it 1.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: f
VeVi e il6,4 , so 1(
(name of hauler)
The debris will be disposed of in
60j V,a=t S
(n me of facility)
=-ei 6,,
(address of facility)
ignature of permit applicant
date
dnd;��ra,x