5 SUMMIT ST - BUILDING INSPECTION s� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
1W Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One or Two Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied .c
'136if-ding Official(Pont T7ame) 3tz'r. rgnature mow; Date
SECTION 1: SITE INFORMATIO
1.1 Property Addr7l C` _ 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimens, ns:
Z -3 l I S
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:. PROPERTY OWNERSHI]'i
2.1 OwneriofRecord:
Y� � 11e-)o 1��! . r�� o \ 9 7o
Name(� City, State,ZIP
No.and Street Telephone Ein re s
SECTION 3:DESCRIPTION OF PROPOSED'WORK Z(check all that apply)'
New Construction ❑ Existing Building wner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_2_I Other ❑ Specify:
Brief Description of Proposed Work':
3 ✓'
w: SECTION4 ,ESTIMATED CONSTRUCTION
COSTS
Estimated Costs: _ ", 'x
Item K Offlcial`Use`Only
Labor and Materials '
1. Building $ 1. Building Permit Fee: $ Indicate how fee is deterinined:
❑ Standard City/Town Application Fee
2. Electrical $
❑ TotalProjactCost;,(ltem6)xmultiplier,r x%�
3. Plumbing $ 2 Other Fees $
4. Mechanical (HVAC) $ List ` G!�
5. Mechanical (Fire $ Total All Fees $
76Toltal
ession
Check No Cl eck Amount. Cash-Amount:
Project Cost: $ 0 Paid iuFull z, . , O Outstanding Balance Due:
SECTION 5: 'CONSTRUCTION SERVICES.
5.1 Construction Supervisor License(CSL) S Z W2 Z z/3
C,SP L License Number Expiration Date
Name of CSL HnkdZr �
List CS Type(see below)
No. a d St et Type sztr b. t ; Description
� U Unrestricted(Buit in s u to 35,000 cu.ft)
City/Town,/Town, State,ZIP 'u 1 1 ° R Restricted 1&2 FamilyDwelling
ty M Masonry
RC Roofing Covering
WS Window and Siding
\ SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration
HIC Company Name or HIC Registrant Name Date
No. and Street Email address
City/Town, State,ZIP Telephone
$c A M
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 TO BE COMPLETED WHEN '
OWNER'S AGENT OR CONTRACTOR APPLIES TOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf to al rs relative to work authorized by this building permit application.
Prin Owne s ame( lectronic Signature) Date
SECTION 7b: OWNER'.OR'AUTHORIZED AGENT DECI ARATION w
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. 0,
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
wcaw.rnass.uov/oca Information on the Construction Supervisor License can be found at www.mass.<gov%dos
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"
i� CITY OF SALEM, l'LxSSACHUSETTS
13LIMING DEPARTM&NT
• ' lr 120\V.',SHLNGTON STREET, 3aa FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI.%BFRT EY DRISCOL
THORUS ST.PIER
MAYOR RB DIRECTOR OF PUBLIC PROPERTY/BUII.DLNG CO\MIISSIONER -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anniicant Information Please Print Leeiblyn
Name(Busiixys.Organizatiarvindividual): Chee a--' Q��� ,
Address: I Lit I In t., ram' pp Cftat
City/State/Zip: Phone k: `1'
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fitll and/or part-time).* have hired the pub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t Z ❑Remodeling
ship and have no employees These sub-contractors have V. ❑ 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 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I CI Plumbing repairs or additions
myself.(No workers'comp. c. 152, $1(4),and we have no 12.❑ Roof repair
insurance required.)t employees.[No workers' (3.❑Other
comp.insurance required.]
;Any appllcum that chucks boa el most alto fill out nhe section below,showing their workers'compensation pansy information.
14"cuwft"who submit this affidavit indicating they am doing all will and them him outside contrscmrs must submit a new alydavit indicating such
!Cowmatom that ch�vk this box most attached an additional sheet showing the nano of the sub,:ontruton and their workers'comp.pulley Infemmtien.
l um on employer that lr providlug Ivorken'compensation/N 1115urunce jor myemployees: Below Is tAe poNcy and fob site
informatiom
Insurance Company Name:
Policy 1l or Self-ins. Lie. 4: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failures to secure coverage as required under Suction 25A of MGL c. 152-can 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 form of a STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Ile advised that a copy of this statement may bo forwarded to the Office of
Investigations of the DIA fur insurance coverage verification
/do hereby c'ertly ruder the puns n wr ales ojperJmry t/rut the iirjararadon provided above is true and correct.
Da! : .�
Ehone 7z
IOJ)ic iad use only. no not write in dies area,to be completed by city or town n/Jlclad
Cityar'fuwn: _.._._ PermitflJcenseq
Issulail Authority(circle one):
I. Board of Ilcallh 2.Building Department 3.Citylrown Clark 4. Electrical Inspector5. Plumbing Inspector
6.Other --- —
Contact Person: ....:..... .._.--.-..._ Phone ti:
i
CITY OF S�AJ.El%I, iAxsSACHLSETT"S
Bt;ILDLNG DEPARTNMNT
A 120 WASHNGTON STREET, 3m FLOOR
" TEL (978) 745-9595
F,ax(978) 740-9846
KINfgFRT RY DRISCOLL
MAYOR THomAS ST.Pmmut
DIRECTOR OF PUBLIC PROPERTY/BU:ILDNG CON IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In 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
I It, S 150A.
The debris will be transported by:
-TDU M(( ('-', C.C5'�
` (name of hauler)
;I I
The debris will be disposed of in
(name of facility)
(address of facility)
cw�zb
si natu crm applicant
Ate
dcbri,�ILdx: