22 SUMNER RD - BUILDING INSPECTION rl The Commonwealth of Massachusetts Town of
( Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 71"edition Building Dept
Building Permit Appli o To Construct, Repair, Renovate Or Demolish a
One- r Avo-FantilF Diveling
This Section For tcta -e Only
Building Permit Number: Date p lie
Signature: ""' ' 09
Building Commissioner/Inspector of Buildings Date
SECTION l: SITE INFORMATION
' ' p,op Adeessh 1.2 Assessors Map& Parcel Numbers
C�` Ma Number Parcel Number
I.I a Is this an accepted street?yes_ no. P
1.3 Zoning In rmption: 1.4 Property Dimensions:
Zoning District / Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.U.1,C.40,134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesC3
7ROPERTY OWNERSHIP'
.1 Ow er of Re r 2a r nt Address for�Se/rv�i�ce: �f ���IS nnature Telephone
SECTION 3: DE PROPOSED WORK'(check all that apply)
New Construction❑ Exsting Buildin ner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
f De c 'plion f r ed k=-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: E
4. Mechanical (HVAC) S List:
5 Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S `� ❑ paid in Full ❑Outstanding Balance Due:
rI
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Npmc of CSL- HpWer
• .—
List CSL Type(sec below)
Address Type I Description
U I Unrestricted(up to 35,000 Cu. Ft.)
Signature R I Restricted 1&2 Family Dwelling
M I Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atfidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7s:OWNER AUTHOR.17tATION TO BE COMPLETED WHEN
AGENT OR
CONTRACIrOR APPLIES FOR BUILDING PERMIT
NAY/ as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to wo uthorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors 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
J. "Total Project Square Footage"may be.substituted for"Total Project Cost"
,
CITY OF SAL.EIM
PUBLIC PROPERTY
DEPARTMENT
n.K.-n.,
Vwraa 130wAsamG ow Smarr•S LZK M&UM3K:serlt 01WM
To-976-74S-9S"* FA)L 9711-7469W
HOMEOWNER LICENSE EXEMPTION
Please Prisit
Data 4.h109
Job Location
Home Owner Address
Home Owner Telephone
Present Mailing Address
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 who.does not posseas a license,provided that the owner acts 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 hetshe 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
EiPUB.t 1 '=
LIC PRc�PRERTY
lam`' DEPART'.MENT
J
I_; \1 II`a..,1':1;811 r # 1.\I I V, \L\ �\
Construction Debris Disposal .affidavit
(re(luired li/r all demolition and renovation work)
In accordance \1 ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
(name name of hatdcry
I he debris will be disposed ot'in
(name of facility)
(a(ldress tit facility)
slgnafwe o pmult applicant p,late