37 SUMMIT AVE - BUILDING INSPECTION (2) I ;
The Commonwealth of Massachusetts
�\ Board of Building Regulations and Standards Town of
Massachusetts State Building Code. 780 CMR, 7'"edition logmagoo
r, Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kmmuwlwa
Orre- r to fmrrih'Dorlling
is S c on F r Official Use Only
Building Permit um c Dale Applied:
Signature: "'h �.. -) /
Budding Conninusisiogrl Inspect f ridings Date
CTION 1:SITE INFORMATION
I.I Property Address: . 1.2 Assessors Map& Parcel Number
1.Is 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(R)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
4r 1 4 XOfrb
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public-A Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if vcsC1
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Rec, rd:
StFrJ c�lti�l���l� Si//�yflrJ 37 Syl^r,i-� (ay,e.
Name(Print) Address for Service:
9�!-7Yr /Or
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)0 I Alleralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Pro sed Work:: r� �—
T ! >�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
m Estimated Cases: Official Use Only Official Use Only and Materials
1. Building S (� I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical f O Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3 Plumbing S 2. Other Fees: S
4. Mechanical IHVAC) S List:
5 Mechanical (Fire S
Suppression, Total All Fees: f
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full O Outstanding Balance Due:
r
1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) GS S s�C� l 1?
'• bT.�G ) O,p�t�� License Numtnr E. ,ua/t on Dute
Naror uLl'C`S�LL- HQl�der`—' ''/I 11 List CSL Type Isec lwluw) V
I e- �a N NuN f'f i l I exl T Description
AJJrrss G ro re f A r'S M P O!$3'� U Unrestricted u to 35.000 Cu. Ft.)
R Restricted 1&2 Famil Dwellin
S. ��J 3 7S'6071 M Mason Only
RC Rcsldennal Roofing Covering
Telephone WS ReslJennal Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Revdential Demolition
5.2 Registered Home Improvement Cont(ractor(HIC) ��/ ��
L-<lt -Ce C- fs 6Ir`uG'I Nf`r j
HIC Compaldy Name orIC egistrant Name Registration Number
C-, of Noel L fi G l r>L 01 Z/, U
A ss / 73'-u 7 S-4N3 Expiration Date
sig4liturfF 0 Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 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 Is ante of the building permit.
Signed Affidavit Attached? Yes....... .. yC7&�
SECTION 7a: OWNER AUTHORIZATI O 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
F���
as Owner or Authorized Agent hereby declare
ements and in rmation on the foregoing application are true and accurate,to the best of my knowledge and
�1i,�riz Agent Date
7Whcnsubstancial
r the sins and penalties of ru
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
istered in the Home Improvement Contractor(HIC)Program), will W have access to the arbitration
or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
bstantial work is planned,provide the information below:
rea(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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may he substituted for 'Total Project Cost"
CITY OF SALLM
� PUBLIC. PROPRERTY
-=� DEPAWINIENT
s..•ti r e \ul \t, \I \ v .II .
III 'I'Y 1; 0;14 I \\ 'i',Y V. '"li,
Construction Debris Disposal At'tidm it
(ictluiicd lbr all demolition and renoc:nion hulk)
In accurdance 11 iIll the sixth edition of the State Building Code, 780 CAIR section 1 1 1.5
Dcbi is, and the provisions of 1IGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal hcility as defined by MGL c
I1I. S 150A.
The debris will he transported by:
Y' Iname it hauler)
I he debris will be disposed of'in
Minc ul licility)
LldJnv. ul lJClli1V1
. LI dlu of pi nut dppllcunl
6
CITY OF S.1 -ENI, �Lkss kcHusETTS
BL'IIMMG DEPAILT LNT ...
120 WASHINGTON STREET, tall FLOOR
TEL (978) 745-9595
F.tx(978) 74&9846
KI-BERIEY DRISCOLL
THOb1As ST.PlEm
MAYORDR
DIRECTOR OF PLBLIC PROPERTY/81:11DLNG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
anollcant Information I _ g� Please Print Leeiblr
Name ldusimv Orpni:atiorvinLbveduall: ++ r — 1 �� C)/J61-(,( j / t)l^/
Address: /� �/✓P o I v N I N 6it
City/State/Zip: G t U��f1!J� P1 OPi'lione H: X-3
Are you to employer?Cheek the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or Part-time).* have hired the sub-contractors
2�1 am a sole proprietor or partner- listed on the attached sheeL : 7. �Remtxeling
,hip and have no employees These sub-contractors have 8. ❑ Demolition
warping for me in any capacity. workers'comp.insutnum 9. ❑ Building addition
[No workers' comp. insurance S. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. C. 152,010),and we have no 12.Q Roof repairs
insurance required.) t employees.two workers' 13.❑Other
comp. insurance required.)
-Any applicant that chd:b aoa If mdur alw fill wr the saerim bahw Anring their warter'rampenMkm policy infummloo.
't Lvtwuwnsaa who subs t the aflldsve indicting they"doing all work and then him outside cont Ulm must submit a non,alRdavit indicating suck
('.utrtsvn that chaek this ten must attached in additiord sheet showing chat muses of the sub a mnasom and their wwkem'comp,policy information.
I urn as employer(hot ir providing•workers'rompensadion Insurance jar my emp/uitem Below Is Meer polley andM r/ors
injormufiom
Iniumnce Company Name:
Policy g or Self-ins. Lic.p: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of The workers'compensation policy deelaratbo pose(showing the polky number and expiration data
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the Corm of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Inviceugatiuna ol'the nlA for insurance coverage verification.
1,16 hereby certify car ,r rho pains and penatles of perjury that the in/armadoe provided above is true and carrecL
Phone47 V �'�
i01ricial use only. Do not write in this area, to be completed by city or town affls-iaL
City or ruwn:
Issuintl Authority (circle one): j
I. Ituard of Ileilth 2. Huilding Department 3. City/town Clerk J. Electrical Inspector 5. Plumbing Impeetor
6. Other
luntact Person: _ ___ __ Phone#: