31 SUMMIT AVE - BUILDING INSPECTION The Commonwealth ofbfassachusetts CITY OF
Board of Building Regulations and Standards
(� ALEM
Massachusetts State Building Code,730 CMR SdMar
1 lYt Revised tLfnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For-Official Use 0nl .
Building Permit Number:-.." Date Applied:;. - ["
.
Building Official(Print Name) Signature D
SECTION L•SITE INFORMATION
1.1 Property Address: Y A 2 L2 Assessors Map& Parcel Numbers
'tir �LN'1 /N
,-1
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 R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate Supply: (M.G.L c.40,§54) 1.7 Flood ono Information: 1.8 Sewage Disposal System:
Public Private❑" Zone: _ Outside Flood Zone? bfunicipal Von site disposal system ❑
Check if yesC3
SECTIONZq PROPERT_V'OWNERSHIFL
2.1 Ownert of Record:
SlC�nn ,2si=t 17.�ho;,,vir
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKr'(check all that apply)
New Construction ❑ JExisting Building Owner-Occupied ❑ Repairs(s) (3 1 Alteration(s YJ Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units 'L Other ❑ Specify:
Brief Description of Proposed Work:
I•'1 a q r •- a.. 4�h N �SECTIOtq 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only..
Labor and(vfateriais
I. Building S /D� �� 1. Building Permit Fee S Indicate how fee is determined:
❑Standard,City/Town,Application Fes-'
3. filectrical S $!X>o
❑"CotalPiojectCost](Item.6)xmultiplier x
3. Plumbin; S u/ 6UG 2- Other F'ees: S
t. Mechanical (IIVAQ S �j' 79J List:
. Mechanical (Fire S
SnP ressimQ _ focal All Fees: S_
Check No, Chcck Auwunt: Cash amuuut --
h I'utal Projcet Cuit S -2
/ f ❑ Paid in Pnll ❑Outstanding Hahllcc Ihta: _-
f
SECTION 5: CONs'l-RUCTION SERVICES
5.1 Construction Su tervisor License(JCSL)
ta/1 License Number Expiration Date
Name of CSL lolder Type below V
7i
_ List CSL Typ (.w'• )
[���
i `, �"'!— Z oc-�- Type Description
No. and eet
q/�U•{sS hAtA-1 U Unrestricted Duildin s u to J3,000 cu. R.
i ODDemolition
ted Ig2 Fmntl Dwcllin
City/Town,State, ZIP r
Covering
w and Siding
uel Burning r\pplianecs
on
Tele hone Email address tion
5.2 Registered Home Improvement Contractor(HIC)
H[C Registration Number Expiration Date
I IIC Company Name or RIC Registrant Name
No.and Street Email address
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 Issuange 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
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..
Print Owner's Name(Electronic Signature) Date
SECTION 7h: 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
cunt. ' n this application is true and ccurate to the best of my knowledge and understanding.
14
Print O, x 's o Authurired:\,ant Y Name(Electronic Signature) Date
NOTES:
I. r n wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(n t r gistered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under DLU.L. c. 142A. Other important information on the FIIC Program can be found at
www m:us.emvtaca Information on the Construction Supervisor License can be found at www.ula. .'wV (Ij,._{
1 When substantial work is planned,provide the information below:
Total tloor area(sy. It.) _(including garage, finished bascmenNattics, decks or porch)
tiro>i living area(sq. it.) Habitable room count _
Number of Ili aplaces...---_------ `'umber of bedrooms
Nuntberotbathrooltt., _-- Number ofhaltbaths _ __ _ _
I of lwming i'y;telll
1)pe of cadin" iy;tenl . -- Fnclosed_--- t 1pcn
I. `I ,tdl I'nq.a Syu.na Pnot.l fit"clay he ;iib;fitnt:,l f,I 1 '1.11 Pmjarl Co X,
CITY OF S.'1LEM, lIASSACHliSETTS
BUMDLNG DEP,ART\L1-_NT
e 120 wASHIINGTON STREET, , FLOOR.
TEL. (978)745 95915
FAX(978)140-9846
KIJiBERLEY DRISCOLL
TtiGhL1S ST.PD?RRB,
MAYOR DIRECTOR OF PUBLIC PROPERTY/BGitDLNG COhL\DSSIONER-
Workers' Compensation Insurance Affidavits Builders/Contractors/Electriclins/Plumbers
p licanf Infortnation ( Please Prin4 Le ibl
NaMC(BusiiwssOrganizalionRndividual): SK�
Address:
City/State/Zip:
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑ 1 am a general contractor and i
1.❑ la employer with ir b. ❑N construction
t to ees full and/or art-time).• have hin:tt the sub�Cache sheet
'
p Y ( P 7. �odeling
2. 1 am a sole proprietor or partner listed on olio attached sheet
ship and have no employees' These sub-contractors have g. emolition-
working for nic.in any capacity. workers'.comp insurance. 9. ElBuilding addition
(No workers comp.insurance- 5. ❑ We are a corporation and its 10.❑ meal repairs or additions P
required) ot'ficers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions
myself.(No workers'comp. C. 152,¢1(4);and we have no:, 12.❑ Roof repairs
insurance required.]t employees.[No workers' 13.❑Othez i
comp.insurance required.] '
Any appllcam that checks bits 91 must also fill out the section below showing their worker'ccmpeosa icu policy mrormatiom -
!1 Inmeuwnar who submit this affidavit indicating they are doing all worst and then hire ealsWe contractors most submit a new,afedavit indicating such.
�Conime:ton that chuck Ibis boa most oil ached an additional sliest showing rho name of the subocontne3os and their woken'comp.policy information. -
am an employer that ft providing Ivorkers'comptitsadon htsurance for my employees. Below its the po/fey andJob site
information.
Insurance Company Name: -
i
Policy H or Self-ins.Lic.M Expiration Date:
Job Site Address: City/State/Zipf
Attach 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 c. 152 can lead to the imposition of criminal penalties of a
tine up to.S 1,500,00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a Gae
of up to S250.00 a day against,the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage veritication. '
l do hereby cent' ds►the ins and pens ies o perjury that the information provider!above is true and correct
i l . .. Date: .S—�� �.3
P,. . d 7�
OjJirial use tly. Do not write in this area,to be completed by city or town of elal
City or Town: Pcrinitfl"icense#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.O titer
Contact Person: Phone#:
i _
C ITY O F S'6UzNi, >bL1SSACH USETI-S
DEP.tRnt>3vT�+,
• /� 120 V'/AS RE
HLYGTON STET 3 FLOO
I-L. (978) 145-9595 R
<I timE2LBY 0RISCOLL Fit(978) 7 W-934S
"'UYOR MON&U ST.PIERRB
DI iECTOR OF PUUUC PROF ERTY/SLMDLYG CO-%W1S5IO.V ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn uccordance with the sixth edition ofthe state Building Code, 730 CIMR section l l 1.5
Debris, and the provisions of tb(GL c 40, s 54;
Building Permit M 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 NI'M c
l 11, s i so,�.
The debris will be tr msported by;
�/
(Hama ut'haulw)
Ake-
The debris will be disposed of in
(name of famlity)
(address of face ity)
siSn nua o(permit applicant
7, ;77-j?
I
(Lnc __