7 SUMMIT ST - BUILDING INSPECTION (4) t
^a The Commonwealth of Massachusetts RECEI x
" Board of Building Regulations and Standards INSPECTIONAL SER65� E F
Massachusetts State Building Code, 780 CMR I
ryry�� Revised kar 2011
Building Perniit Application To Construct, Repair, Renovate O rJYNstl J A If: 02
One-or Two-family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
11 I
Building Onicial(Print Name) Signature D;tt
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map lk Parcel Numbers
1.1 a Is this an accepted street'?yes_ no klap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning D"('" Proposed Llse L,o[Area(sy It) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(bLQL,c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ lone: _ OUISide Flood Z(ale� Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSFIIP'
2.1 Owner'/o�fRecord:
nf4o
Name(Print) City,State,ZIP
So�mm >` S� _ �e 3(��03 � ( CF�rtCQ beer 18�Q
No.and Strct Telephone Ismail Idmss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 9 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specily: _
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
I. Building $ / UOG 00 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing $ 2. Other Fees: $ �
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire-Suppression) $ i Total All Fees:
6. Total Project Cost: $ I G 0&, Check No. _Check Amount:__Cash Amount:___-
i 0 Paid in Full 0 Outstanding Balance Due:_
SECTION 5: CONSTRUCTION SERVICES
5.1 Constnictipn.Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder �.
i' �i ( i ". Ii% List CSL'I'ype(see below)
No.and Street Type Description
IJ Unrestricted(Buildings u2 to 35,000 cu. ft.
R Restricted 1&2 Farnily Dwelling
City/Fown,State,ZIP M Mason
ry
RC Rootin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Tete hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IiIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 'Fele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NI.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 FOR BUILDING PERMIT
I, 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.
ea-1-1AI(a— rre-(-C tD A'f /-/`/
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
/ t
Print Owner's or Authorized Agent's Namo(Ilectronic Signature) Date
NOTES:
I. 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 Florae Improvement Contractor(MC) Program), will not have access to the arbitration
program or guaranty fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.nress.,ov/oca Information on the Construction Supervisor License can be found at www.rnass.eov/doS
2. When substantial work is planned,provide the information below:
Total Boor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R) 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"
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CITY OF SALEM, MASSACHUSETTS
i�= . :•• R� BUILDING DEPARTNIENT
120 WASHINGTONSTREET,3"D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TmmAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONVVE SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 6 -1/'/6/
Job Location 7
Home Owner Address__7 Sti✓n m,{ SfC2m � G� �70
Present Mailing Address 7 .Sr ins �! S / SCtIQv✓/ Mc�_ of 76
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner' shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR