30 SUMMIT ST - BUILDING INSPECTION F -
The Commonwcalth of Massachuscits
I�J Board of Budding Regulations and Standardslad:bftl�
I � .Massachusetts State Budding Code, 780 Ch1R. T"editionpt
Building Permit Application To Construct, icpair, Renovate Or Demol
One- or Two-Fomtls Dwelling
This Section For lficial Use Only
Budding Permit Number' \ Dale Applied: zJz
Signature:
Building Co s oner/Inspect r
- f dings Date
T ON 1:SITE INFORMATION
1.1 Property Addres : / 1.2 Assessors Map d Parcel Numbers
3o T
I.I a Is this an accepted street:?yes I 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)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40.l54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site dis sal s stem D
Public O Private O Check if esO pO Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
X
N 1 int) =110aJ&C
Address for Service:
G�—?8 -`)(—/�
s g<t ture Telephone
SECTION J:DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) O 1 Alterstion(s) O Addition O
Demolition O Accessory Bldg.O Number of Units Other O Speclf}:
Brief Description of Proposed Work':
�i=tE4:2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item4(HVAC)
Estimated Costs: Official Use Only
Labor and Materials
I. Building I. Building Permit Fee: 5 Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical ❑Total Project Cosl'(Item 6)x multiplier a
J Plumbing 2. Other Fees: f
4. Mechanical List:
s Mechanical (Fire S Total All Fees: S
Check No. _Check Amount: Cash Amou
Suresstonnt:_
6 Total Project Cost S 0 Paid in Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL)
Lrrenw Number Esprrution Date
N•4rac of'CSL Ifgldrr List CSL Type(xcc helow)
Tvoe I Description
A Wress
U I Unrestricted(up to 13,000 Cu. Ft.
R I Restricted Ih2 Family Dweltin
Signature M I Masonry Only
RC Residential Rooting Coverm
Telephone WS Residensal Window and Siding
SF Residential Solid Fuel Burnme Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Rel{tstratton Number
Address
-Expiration Dale
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 152.1 2SC(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 Afiidsvit Attached? Yes.......... O No........... O
SECTION 7s: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 matter
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate, to the best of my knowledge and
behalf.
Print Nuts
Signature of Owner or Authorized Agent Date
(Started under the Permit and penalties of perjury)
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 HM have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on(he HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenNattics,decks or porch)
Gross living area
(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
Typeof cooling system Enclosed Open
1 "Total Project Square Footage"may he substituted for"Total Project Cost'
CITY OF $ALENA
PUBLIC PROPERTY
DEPARTMENT
'
VON 130 WA9uNa10N STEM 11UAK.MAS&AO LS1r 71019'0
TEL 97L745As"•FF%3c.9711-7W90e
HOMEOWNER LICENSE EXEMPTION
Please "t
Date I b G °�
Job Location
Home Owner Address 124-� -
Home Owner Telephone 7 k- 7 3 9 3 -5— X
present Mailing Address S
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
hue who does not possess a license.provided that the owner act@ as supervisor.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
gPUBLIC PROPRERTY
%lo
DEPARTMENT --
— Dom/
,nnr nlrs
j20 W.\iIIINGI(\NSI J(Err
'frt:VS-74i-9595 ♦ f:\3:978J40�9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance will, 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
C rl�f?'cS
(name of hauler)
The debris will be disposed of in
(name of acl ity)
i
(address of t'acility) �Q
signature of permit applicant
/o l g 117
da