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23 SUMMIT ST - BUILDING INSPECTION The Commonwealth of Massachusetts MR L $ER,Iy� g = Board of Building Regulations and Standards ISALEM Massachusetts State Building Code, 780 CMR :IOIb MAR 1 lrtti/�i(�011 NBuilding Permit Application To Construct, Repair, Renovate Or.Demolish a ( One-or Two-Family Dwelling n This Section For Official Use only —V Budding"PermitNumber.' Date Applied: (� building olticial(Print Name). Sigmture Date Y SECTION l:SITE INFORMATION` 1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers t �>1 r� tN- � T S'T I.1a Is this an accepted street9 es no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District .. -Proposed Use - Lot Area(sq R) Frontage(11) 1.5 Building Setbacks(R) . . . Sidi Yards Rear Yard .. Front Yard � " Required Provided :Required Provided- Required' Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood one Information, 1.8 Sewage Disposal System: Public O Private❑ Zone: _ Outside Flood ZoneT Municipal O On site disposal system O- Cheek if C9O' . ' SECTIONZ: PROPERTY OWNERSHIP! 2.1 Ownert of Record: G A'3R t c.L Z�J P\r�o M (a N7 me(Print) City,State,ZIP 2 '� 5y -% t~ \ -(- �r S1 oS No.and Street Telephone EmailMdren SECTION.3: DESCRIPTION OF PROPOSED WORK°(check all that apply) New Construction O Existing Building O Owner-Occupied ❑ Repair(s) O Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ NtunberofUnits Other O Specify: Brief Description of Proposed Work-: T P SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor anJ Materials �. - r I. Building $ ( ��p 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical ❑Total Project Cosh(Item 6)s multiplier s 3. Plumbing S 3?Qther Fees: S q.Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees:S Su ression) OOoo Check No._Check Amount: Cash Amount: G.Tutai Project Cost: S 0 paid in Full 13 Outstanding Balance Due: J,,*•,'. !?J 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ;; 1 License Number Expiration Date Name of CSL Holder List CSL Type(see below) Type Description . No.and Sued - U Unrestncted DuilJin a to 35,00 w. ft. R Restricted 1.@2 Fami1 Dwellin C ityfFown,State,ZIP M masonry RC I Roolin Coverin WS I WindowandSidin SF Solid Fuel Burning Appliances 1 Insulation Tcle hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date I IIC Company Name or HIC Registrant Name No.and Street Email address cityrrown,State ZIP Telephone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G-L c.152.§25C(6))t, Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the)sivance of the building permit. Signed Affidavit Attached? Yes ..........13 No...........O SECTlON7a:OWNERAUTHORIZATIONTOBECOMPLETEDWHEN ' OWNER'S AGENT OR CONTRACTOR APPLIES FORBUlI.DING PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) - Dale SECTION 71b:OWNERt OR AUTHORIZED AGENT DECLARATION By entermd my name below,I hereby attest under the pains and penalties of perjury that all of the information co a' this application is true and accurate to the best of my knowledge and understanding. (�?L SW PP Nfl n� in is or Authorized Agent's Name(Electronic 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 Home Improvement Contractor(HIC)Program);will glyl have access to the arbitration — — — program or guaranty Fund under M.G.L.c. I d2A.Other Important inTormanonn on the HICYFogmm can be loon of--------- - --"- �ew.v max, eov'oca Information on the Construction Supervisor License can be found at wwtv.mass.�ov/Jns . 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) N .(including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type ofcoolingsystem Enclosed Open 3. -rota) Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM, MASSACHUSE M BUILDING DEPARTMENT' 120 WASHNGTON STREET,3ftD FLOOR TEL. (978)745-9595 KIMBERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMAS STTIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER HOMEOWNER-LICENSE EXEMPTION PLEASE PRINT: / Date © 5 Job Location s U M I`.. k ( -C�,T Home Owner Address Present Mailing Address ) Q v j \ 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 re ements and that he/she will comply with such procedures and requirements. 1- HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSIDE T R � FT SHOWCtZ �31�SC� M ��T i 0 a I° C Lo06� CITY OF SALEg MASSAC HLBE M BuionyGDEPAjmvm 120 WASINSIMMS7=7,3IDR DOR UL(978)745.9395, PAX(978)740-9846 R1MRFi�i.*'.YDRISQ'�LL MAYOR THCMAS STTIEM DIRECTOR OP P[1aucPRamm/BumDm S57O7,R Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by. LV51 t�c_e (name of hauler) The debris will be disposed of in: \,d oO p w (XS-y<- o f C'�oS1 D (name of facility) C- N` (address of facility) r Si at re of applicant Date