51 SUMMIT AVE - BUILDING INSPECTION (2) y --- I'lie Conullonecahh ul�1us+uelnuclts
r Board of Building Regulations and Standards CI'I'1' OF
1 11 'vraMichuscIls Stec Building Code. 780 C NIR SALEM
I 1 Building I'cnnil ,\pplicatiun 'fo Construct. Repair. Renovate Or Demolish a
(AIL" ur run.A'anu(r DuLllin•tr
This Section Fur Olricial Usc Old j
Building Permit Number: Uat ed
IuilJmy(11116A(Print N;une) aaturc bale '
SECTION 1:SITE INFORMATION
.1 Property Address: 1.2 Assessors Alxp di Parcel Numbers
SI SJMMIT AdE _
1.la Is this an acre led street?),es no-- �Iap Number I'urccl NumhLr
I.-) Zoning Information: 1.4 Property Dimensions:
Luring District I'milmW Lisa Lilt Afea 114 11) Froolaye(I"
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided
1,6 Witter Supply:(M.G.I.c. J0.§!J) 1.7 Flood Zone Information: 1.8 S1wagt Disposal System:
Ihablic❑ Prds ate❑ Zone: _ Outside Flood Zune7
Check if cs0 Municipal❑ On site disposal s).rlem ❑
SECTION I: PROPERTYOWNERSHIPt
2.1 Owner'of Record:
R 4S rAtGrW4110 LE IC t)ArOE�Nitc SALEM MA O/976
Naune(Print) City.State.1111'
ArF_ 7&/ 920 d233 Re ra D_%w eMFwry �ryesK rtsT. Fi
Nu.and Sareet relephune Entail Address
SECTION!: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ E.risting Building)i!�— Owner•Occup(ed%1_ Repairs(s) V- Alteratlon(s) ML Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units 2 Other ❑ .Spccily:
Brief�Description of Proposed Work':
/� _
EPCkcE OLD arrdpoos W,T4
SECTION a: ESTIMATED CONSTRUCTION COSTS
licill Estimated Costs: 0111c1o1 Use Only
(labor and .Materials) y
I Building S /O 0D0, I. Building Permit Fee: S Indicate how ice is JI
'. 1:'Iccuical S ❑Standard City.'Tutsn Applicalion Fee
❑Total Project Cost l Item 6)x multiplier _ __
t I'lumh10g S S, Other Fees: S ------- �
� J. \Iccli.ulic.d ill1 1(�1 S List:
'
—'— —. ...
�ulyK�s aunt S r✓tat 111 Fces: S_n I'ulal Project Cn.l: i /O 000 ' ('heck \u. -_ __Check .\nunmc - -. .._. .(',t,h \ w lnml:
0 P.lid in Full IJ Oulstanding Ilal.mce Due
SF.( I IONS: ONS I-RI[CrION SERVU FS
I Ioldcr
k PC I)vskription
,trvkt ki t'nrt;s(roAvd tiltold ol�s tip to limoo'u. II.I
It lic'Imled I&I 1 .111111) D%w1ling
1W
%k S Wiodow xid sol"IM
SF Solid 1.7ual Ilurninit Appliances
I Insulation
1'ek hunt ---------- D Demolition
addrvmi
$.2 Registered I Ionic Improvement Contractor(111C)
IIIC ItegiAration Numbur F%viration DJIV
I IIC Colopin) Name or IIIC l4egistrunt Njing
[:mail address
No. and Street
i own, State,ZIP 'role hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 153. 1 25C(6))
Workers Compensation In affidavit must be completed and submitted with this application. Failure to provide
this atYidavit will result in the denial of the Issuance of the building permit.
Signed A Mdavil Attached? Yes .......... 0 No..........0
SECT — IONIPLETED WHEN
ION 7s:OWNER AUTHORIZATION TO BE C
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.
Dale
ic.sillnuture)
SECTION 7b:OWNERt OR AUTHORIZED GENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties orperjury that all of the information
contained in this application is true and accurate to the best ormy knowledge and understanding,
14---\ L
S' 1,7 A,
lu - nulk;
Prim Uoner't or.NwhorindAvol'.*Name(VIcIUMIN Sitla,itttrol
NOTES:
to do his her own %wrk,or an owner who hires an unregistered contractor
I. .\nO\�ill:f \�hoob:taii:isa:buil:ding:pertiiit
(nut registered in the Home Improvement Cuntrac lot(H IC) Pro grant 1,will 1U) have access to the arbitration
G L
, . -r M.G.L.
I :
Fprogram or I;uuranq Fund under M.G.L. v. 141A. Other important information on the HIC Program can be Ilowid at
ro'.1t L ,
ion on the Construction Supervisor License can be found at Z;!.% .111,
i Informal )
is o k
2. \%lien substantial%kork is pl;1noci•pros ide the hilbriontium below:
r r 1 11 ____.._(including garage, iiinishcd basement-11fics. decks or porch)
otai ilour are,'(4 if�ibit.ihld room c0i"'I
Croisiisoigareaiiq 11 1 ....
\twiher kit hedrokims
I peol Iwmiog i)'Mn
I I":"fo,olilIQ slain
I Joi.0 11roickt tiqtmry I ool-Ice MA% loial 'rojek:1 C+"I"
CITY OF S-UYDvI
PUBLIC PROPERTY
DEPARTMENT
co��ruar c.au�u
w.ae 13e WUDWMG ou!runs•guars VAolorasere Otre
ru.CY.715-95fm•VAL f7L7467Ne
HOMEOWNER LICLNSS EXE.I "10N
Plow rrtsa
Date s/,,;,h
lobLoeadoe 3/ .Summ,T AVE
Hones Owner Addreaa s/ soon rn o r h vE
Home Owner Telephone 7s/ a`2 a c 2 s s
Pre"d N(ailiatil Addnn S/ symn Y7- AVE
Tjje current exempdoo of Homeowners"was extended to include owner-occupied
dwellings of two Units or fens end to allow.ruck homeowners to engsge m individual for
hire who does not possess a 11cense4 provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a pared odfatW an which he✓she teaidee or intends to reside,on
which then is, or is intended to be,a one or two family dwelling, attached or detached
swxttsres accessary to much use and/or farm sWxturea A person who conunacts more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall Submit to the Building OQlcial,on a forth acceptable to the Building
Otilcial, that hdshe be responsible for M such work performed under the Building
Permit.
The undasigrsed "honseownce assumes responsibility for compliance with the State
Building Code and other applicable by-laws and relfuladons.
The undenigned "homeowner"certifies that hedshe undentands the City of Salem
9WIding Department minimum inspection procedures and requirements and that hedshe
Will comply with said procedures and requirements.
HO-tEOWNERS UGNATL'RB e.vxy
.APPROVAL OF BUILDING CiSPECTOR
See other side for state code
CITY OF 5.1L&N[9 )A"S.ICH[;SE- TS
" ULLONG OEl•.1R ONO
I'0 WASHLNGTom SrIMM, ile accit
rEL k978) 743-9393
KJUM F L SY 01=OLL FAX(978) 744984d
NWOR MOMU ST.PMUS
D fRFC'CO!<OP Pl:BLlC PROPERTY�BI'ILDLYC C01p1133tON E�
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 780 GAR section I 11.3
Debris, and the provisions of MGL a 40, S 34;
Building Permit At is issued with the condition that the debris resulting from
'his work shall be disposed of in a properly licemed waste disposal racility as defined by,blGL c
111, S I30A.
The debris will be transported by:
%f sejx Z! P•T
(n4me of hauler)
The debris will be disposed of in :
C—OVAt4TA
(name or 6171 r)
i,ddn�r arn. l„y)
iyn�rureo(;,ermit ,pplw.nt
86• /7 • /2 _
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