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47 SUMMIT AVE - BUILDING INSPECTION (4)
The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards Ulf Massachusetts State Building Code, 780 CMR SALEM Revised kar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One or Two Family Dwelling ate, ; 1.1 Pro rty Address- 1.2 Assessors Map&Parcel Numbers -'/.F SAr-w,",r ve — — 1.1a Is this an accepted street?yes P/ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required F Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Er Private El Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yesO 2.1 Ownerl of eco IWA 0jq70 Name(Print) City, State,ZIP r sT 7yo Z--- No.and Street Telephone Email Address a New Construction 0 Existing Building plrOwner-Occupied W"rRepairs(s) Alteration(s) El Addition 0 Demolition 0 Accessory Bldg. 0 1 Number of Units _ I Other 0 Specify: Brief Description of Proposed Work : ge.,,owArc- v x.,ar,,j!h etjO Floo-c- 7Z�A7-4'91d6V—V\ 33 Estimated Costs: Item (Labor and Materials) OW, Hs�'k I.Building 2.Electrical $ 373-o X, 3.Plumbing $ &Joav— 2 O erg 4.Mechanical (HVAQ $ 5.Mechanical (Fire Suppr ssion) Ee SAaa� .t SECTION Si'CONSTR_UCTION SERVICES 5.1 Construction Supervisor License(CSL) &Zco9 A N VTA W ,P4 t,Lia-y— License Number Expiration Date Name of CSL Holder 3 List CSL Type(see below) 2- � �Z No.and Street s Type Description oPSFxJ Q hN Q O L qO�3 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town, State,ZrP M Masonry RC Roofing Covering WS Window and Siding n SF Solid Fuel Burning Appliances o GQy/\ I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) \ 1 _ — , i36ID alty t3 Y• ` 94``'t'o t NL— HIC Registration Number Expira ion Date HIC Comp�any Name or HIC Rego tr t Name 32 Yin Rwz t V") c�a r� Q cY a n p t Lpel No.and Street Email address 'raor¢,ECD. MA o��v3 g28887-??,q City/T own, 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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TORE COMPLETED WHEN , OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize �C C&#J T*A C7— 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 7b: 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 contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at wrww.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eovi'dns 2. When substantial work is planned,provide the information below: Total floor 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/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' • t ,s i CITY OF SiU.EN1s AxsSACHUSETTS BULMNG DEPARTMENT t !� 120 WASHNGTON STREET, 3m FLOOR TEL (978)745-9595 F.+x(978)740-9846 Kl.%fBERT R.Y DRISCOLI. ' MAYORTHORL►S ST.PIERRS DIPX=Clt OF Pt.BLIC PROPERTY/BCILDNG CONNISSIONER - Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilleant information ` Please Print Legibly Na1tic lBusiti ss '�orgtnization/Individual): V k) 14 % LIFE 46 t to Address: 3 Z C IEaMl� City/State/Zip::" sf-ac(QW4 0191B3 Phone ht: 9 7 B ' ®Pi? l ug Are you an employer?Check the appropriate bean 'rype of project(required): 1.❑ I am a employer with U 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(flail and/or part-rime).• have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• []Remodeling ship and have no employees These subcontractors have S. ❑ Demolition working for me in any capacity. workers'comp, insurance. 9. Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their l0.❑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,¢1(4),and we have no 12.(3 Roof repairs insurance required.)t employees.LNo workers' IJ.Q Other comp,insurance required.] •nny appllc:ua riot chucks box el must also,NI out the secrioa bclowsltowing thou worker•compensadun polic infurmadon. Ihvnuuwtsera who sulmiit this affidavit indicating they am doing all work and then him outside conrmet=must submit a now,amdavil indicating wch :Conimotor,that check this box must attached an additlunai sheet showing the notne of the subcontractor and their worker'comp.policy infemuid'o. lion ate employer that is providing workers'compensadon Insurance for my employees: Below is flu po/fry and Job site injormatioa, Insurance Company Noire, Policy a or Self-ire.Lic. H: Expiration Date: Job Site Address: City/State/Zip.- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section25A of MGL c. 152can lead to the imposition of criminal penalties of a tine up to S1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investigmimis urthc DIA for insurance coverage verification. i do hereby a ert6rj under the pulps and items/des of pert ory that tire information provided ubbve is true and correct. Sicnalur � Dore: AZ, 6,' 2-- Phone578� 72f OJjici tf use oely. Do not write in dds aretr,to be completed by city or town allIciaf City orTuwn: ___ PcrmitR.lccmep __ Issuing Autltorily(circle one): 1. gourd of lieallh 2. Building Department 3.City/fown Clerk 4. Electrical Inspector S. Plumbing lnspeetor 6.Olhcr __ Contact Person: Phone ill: J • CITY OF S�U.E1i, NL-�SSACHLSEM BL.ILDL\G DEPARTMENT j/ 120 WASHLNGTON STREET, 3' FLOOR a TEE. (978) 745-9595 FAX(978) 740-9846 KIN{gFRT F.Y DRISCOLL i4giYOR THotitAS ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BCILDNG CO-W JISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) Tn accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 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: £R,tc. Z ©IS t3os& (name of hauler) The debris will be disposed of in (name of facility) (address of facility) - signamra of permit applicant 6 date aend;utfd;w • 1 . Nlassachusctts- DcparUncnt of Public Sal'cty 1 '. _ Rculations :unl Standards Board of Buildin Construction Supervisor License license: CS 62079 '•�' - DANIEL W-PHILPOT} ¢ 32 PEMI3ERToN,tTOPSFIELD, t tl983. Expiration: 112812013 Tr#: 8518 0f III ceor�!onsumrr«o�a HOME IMPROVEMENT CONTRACTOR Registration E1123610 - Type: 15.9'pillhilpotExpiration 3F1Z2013 Private Corporatio Co. INCH-= - .�Daniel Philpot , 32 Pemberton Rd ?' `-',i •= g _ Topsfield, MA 01983'"•��r Undersecretary