32 SUMMIT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Jannury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1008
One-or Two-Family Dwelling
This Section For Official Q4 Only
Building Permit Nu r: 4 Date p
Signature: 4w-,�
Building Commissions Inspector of Buildings Date
SECTION I: I E INFORMATION
1.1 Property A dress: L � ��" "' >� 1.2 Assessors Map& Parcel Numbers
X 3� Ell l'71/Jn I / Aw S4-rn
I.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 It) Frontage(11)
I.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?
Public❑ Private❑ Check if XesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'r Record j>/ `C FS ZL`G��h_
Nome(Print) /"- Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
X Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': e K 5-CX 0 a
rh Ewa �toa7ys r6a.,�hrorwris, ikke:», '1nA9s2P ,rv'aw.v 6/ege 60e? g
a r o f� �P/l�r�Yi'7! r it d A.lr 1f rn :a.. 7n-r /' A
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omcial Use Only
Labor and Materials
1. Building S 2 el,000 I. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x (�
3. Plumbing S 2. Other Fees: S
x 4. Mechanical (HVAC) S List:
5. Mechanical (Fire S l`u
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_ 3
6. Total Project Cost: S � 3 ,O o ❑Paid in Full O Outstanding Balance Due: Ti
Vv
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 4/ 0/13 j /7-2011
License Number Expiration Date
ame of C'SL-I]older 4J �' List C'SL"fype(see below)
0 G/1
/� r Des,d eon
Adrcss r U I Unrestricted(up to 35,000 Cu.Ft.
R I Restricted 1&2 Family Dsvellin
Signature M Mason Onl
�11-6'2Z-327 RC Residential Routin Coverin
Telephone / WS Residential WinJow anJ SiJin
SF Residential Solid Fuel Bumin A fiance Installation
D Residential Demolition
5.2 R Isttered Ha Improve ent Contractor(HIC)
n y �`^ n97M O-j Registration Number
WI 'Company Name or IIIC egistmnt Name
i r , o !
AJ'rii�-+--.1 17f/ j 1,2 fh Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c. 152.4 2SC(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...........0
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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
X behalf.
"W r
Pr i ame
ignalure of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
1. 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(H IC)Program),will jol 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/baihs
Type of heating system Number of decks/porches
Type o'cooling system Enclosed Open
J. "Total Project Square Footage"may be substituleJ for'?oral Project Cost"
CITY OF SM-E.`[, NLISSACHUSEM
BLBm1NG DFP.\I;TSIE.*1T
120 W.kSHINGTON STRM. )era FLOOR
Tt+L (978)745-95911
F.%x(978) 740.9846
KBCDER"Y 01 1SCOL.I. THOWSST.Pt1FJtRs
HAYOt DIRWMIL OF PC eclC PROPERTY/mCILDIVG COSOOSSIONIEM
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricisns/Plumbers
s t Ilesnt Infnrmatlae ,+ Please Print Legibly
NalneIaunru+aCrt,utrtariorblrohviduall: �!�P/� SO "'//?—r
Address: '�,f 115;0eEST ST
city/state/zip. &21 09 6, Phone M. 3�7-1-ov -532-7�t�3
Are you to employs'Check the appropriate boa: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a ginenl contractor and 1 & ❑New convection
'Playtex(full and/or part-time).• have hired the sub-cantractas
�,}^ listed on the attached shiest 7. ❑Remodeling
I.Ll 1 am s solo proprietor�x paMer-
+hip and have no employee Them orb-cownwan have M. ❑Ikmolition
working rot me in any capociry. workers'comp.indictee. 9. Q Building addition
I No workers'camµ insurance S. Q We are a corporation and is I0.❑Electrical repairs or additions
mquiml.l ollkaa have exercised their
).Q I am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing repairs or additions
myself.INe workers'comp. c. 152.41(41 mid we haw no 12.0 Roof repairs
insurance required.)r employee.LNG w 13.00
comp insurance required l
'Ant appbuo the axed.but At mar alto ran vet the seem'blow lowing date 0Y.a'ounpumalos polky lefiwmaYsa
't I.Wwuwrwla who subwit Al@ aAldeve idloNer char as Joins all tad and that him.torsi con nest Now Mine a rw aAJrve irdioritte OmL
:c'.Nrratars rhr chuck ibis but terse anaelud at.nldtirtrd Jrr drewine rive awe of rite alealllierrie arrd rhelr wwkwe'm^7•pdkr iofanrtlob.
r uar on earpleyer that Is prevldhrg workers'coiNPenmden/asstmmw jar toy employ"& Oehw fs the po/ley ewdm sib
information.
Imurance Company Name:
Policy 0 or Self-ins. Lie.A* Expiration Dote
Job Site Address: City/Statetzip:
Attack a copy of the workers'compensation policy declaration pap(showing the policy number and expiration dalo)6
Failure to secure coverage as required under Scctime 25A of MGL c. 152 can lad to the imposition orcriminal pandit"of■
fine up ro S 1.s00.00 and/or one-yet imprisonment.as well as civil Penalties in the form a(*STOP WORK ORDEK and a Ace
Of up to S250.00 a day against the violator. Ile advisor!that a copy of this statement maybe rurwurded to the 01TIce of
Invc.hyatiuns ol'11te n1A for insurance covcrap veritieatial.
J da hereby Certify under the pains un n /s a/perjury that the injorwadem provided above it true rnd cornea
�,
Phone J.
ngra'i.l use Jn/y. no/o or Write In this are*to be cumpkied by airy or rowa,.//4-i I
I
City or ruwn: PcrmiNl.Iccnu l__
lcsuing.ttuthorrly (circle une):
I. Iluard of Ilvallh 2. Ruildlnll Department ). Cityfrown Clerk !. Electrical Inspeclor S. Plumbing Impettor
6.Olher
L.rnlaet Person: . _ _.. Phone M:
,S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..r.u:: sir\ •KIM .1I
\I wo I!Q V('A if II.\I.N?V SrICUT •S.\I I M.NIA i.\t I❑ Q �•:1'I':
'I'FI:'/7t-N 9i9s I°.\x:979-74S92146
Construction Debris Disposal Affidavit
(required rur Lill demolition mud 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 q - _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
i 5'PO S CAL o f A/c W ro ot/
psame ot•pauper)
I•he debris will be disposed of in :
(name ul aci rty) '
(address of IaciGty)
VV signature of permit applicant
3 �5 �01
, le
ACORD n CERTIFICATE OF LIABILITY INSURANCE MMIMM
03/26/2008
PRODVOER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Richard Bertolino Jr Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1200 Salem St #121 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lynnfield, MA �01940
INSURERS AFFORDING COVERAGE NAIC#
QED INEURETA Western World
M.Sotiri's Painting And Masonry INsu�ns
38 Forest St Nsurteic
Peabody Mass 01960 INSIrRERa
978-532-1703 IISINER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Lm NSRO IYPEOFNSURANCE POLICY NUMBBi POLICY EFFECTVE POUCYENTMTON ��
MMIWAIT "m(mmawm
A NPP1225149 05/27/2009 05/27/2010 EACH OOCU E E1,000,000
X GOIIMEBGALOElS3Y1 uAaLrn - PRmIEEs(FeowvNwe) $1,000,000 -�
X X cwMSM �occlm Mm E%P yvry ale Pe/tan) $1,000
PBRsoN.Laarn INJURY E1,000,000
GFJJH+AL AGGREGATE $2,000,000
GFM AGGREGATEUMITAFPUES PER: PRODUCTS-COMProPAGG $1,000,000
P UcV oc
ADIOMOBBE IMBSIIY
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ALL OWIhD AVTOS
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OFFICER/A9RER IXCLUDEOi EL DISEASE-EA EMPLOYEE E
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SPECML PROVISgNS Oebw EL DISEASE-POLICY LIMIT E
OTNER
OESCR�TION OF OPERATONS/LOGTMa/VEMCLES/IXCLBSNIN9 AOOED BY ETIDMISEMEM I SPECIAL PROYL41Ma
CERTIFICATE HOLDER CANCELLA71ON
EINmn ANY � TIE ABOVE OaME1NEO POUCH BE CRNCalm EEFa1E TIE EIIPStAIiON
DME Tff]EOF, TIE mumm ODURER wi L PNDFAVOR TO MAR 10 DAYS YiRRIQ1
NOTICE m Da CERTffN:ATE 11mDER NA TO TIE LEFT, alf iARURE TD OO 90 6W
ll 0 NO OBIAATON OR LMFIBJIY OF ANY NDID UPON 111E SATURER. NE AOEMS OR
REPRFJLENTATNEA
AUTIOR®REWiEBEMATNE
Richard Bertolino
ACORD 25(2DOU08) 0 ACORD CORPORATION 1988