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32 SUMNER RD - BUILDING INSPECTION SO ' cl� l �t �Z The Commonwealth of Massachusetts 'f Board of Building Regulations and Standards 1 t� 46F Massachusetts State Building Code, 730 CMR SALEM 1016 SEP —b Pt-{ "e 2011 O i Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Fmnily Develling This Section For Official Use Only Building Permit Number: Date Applied: 1 Buildme Official(Print Name) Signature Date `L SECTION l:SITE INFORMATION t.l Property perry Address: 11Z Assessors Map&Parcel Numbers l.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas ( 9'ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required IProvided Required Provided 1.6 Water Supply:(M.G.L 54) 1.7 Flood Zone ln!ornmallon: l.g Sewage Disposal System: Public®'� private❑ Zone: _ Outside Flood Zone? Check ifyes❑ Municipal P-6n site disposal system ❑ SECTION 2: of Record: PROPERTY OWINERSIUpl 2.1 O�vnert Name(Print) nnt City,State.ZIP No.and Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ Re airs s DemolitionAlteration(s) ❑ Addition ❑ iefDescription ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: BtofProposedWork AKcz nGh�—� N Kz �_ _ �.v •^_a rsAb. r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building S Q L Building Permit Fee: S 2.Electr cal S ❑Standard City/Town Application Fee ate how fee is determined: 3.Plumbing S ❑Total Project Cost'(Item 6)x multiplier x 4.Mechanical (HVAC) S _. Other Fees: S List: 5.Mechanical (Fire Su ression) S Total All Fees:S 6.Total Project Cost: S Y"' Check No. Check Amount: Cash Amount: d t ❑Paid in Full ❑ Outstanding Balenee Due: of Iz q : Lf. ', SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1i? orvN��v �lmhon .t. License Number Expiration Date Name of CSL Holder i�,p��� }� List CSL Type(see below)__ No.and Street GJ Type Description �j�/i✓„_,.., �t.T yr,�. U Unrestricted(Buildin s u to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roodim,Covering WS Window and Siding (/ 'HG3G� t7C/iw sy`d Ci'M.ryLe�lc t SF 11-Solid IInsulation Fuel Homing Appl aneca L 1 insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HICCompany Name or HIC Rep1s_aant IN HIC Registration Number Expiration Date IC7c/ N and Street Ema /A-4-:7owe il address Cl /Town,State ZIP Tzle hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 25C(6)) Workers Compensation Tnsurance 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 .......... 0 No. SECTION 7a:OWNER AUTHORIZATION'O BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERtYHT I.as Owner of the subject property,hereby authorize /3/)C /� � r i—z to act on my behalf,in all matters relative to work authorized by this building permit application. Fort Owners Name(Electromc Sirena[ure) =— r��- Date SECTION 7b: OWNFER' OR AUTHORIZED AGENT DECLARATION By entering my namc below,thereby attest under the pains and penalties of perjury neat all of the information contained � issapplication is true and accurate to the best of my knowledge and understanding. a v �' P t Own r s or Authonzed a nt s Name(Electronic Signature) •f ,Li47 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 rzg stered in the Home Improvement Contractor(HIC)P7O�l'am),will not have access to the arbitration program or guaranty fund under M.C.L.c. 142A_Otlrer important information on [rte HIC PtOgI'dm can be found at =�- ''::� �`.Itifotri7ation ou the Construction Supervisor License can be found at __ -_ 2. When substantial work is planned,provide dre information below: Total floor azea(sq.fr-) (including garage,finished basemenUattics,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/ orches Type of cooking system Enclosed P Open 3. "TOtal Project Square Footage”may be substituted for"Total Project Cost" r CONSTRUCTION, LLC commercial • Residential Massachusetts Department of Public Safety �? - - 6Board of Building Regulations and Standards License: CS-059344 Construction Supervisor ";,;.. BRETT S EMERY 19 KELLY RD SALEM MA 01970 t . e r � JZUC CA__ Expiration: Commissioner 09/25/2018 LICENSE tl u.aa w tSS �'.''Fi+G 9a Et1115 as MN.IO� �Y � Z. ONE 53145D79U t d7 NONE is sec`M Y 2 g L ,mow-'� x a 19KE KELLY e ,MA' `34 'SALEM,MA 07970-0374 �� � ��5 W f0-pCIDtl WVOt-1SID09 � � ie r��C IfOgrinornnca�/�n/G�(lGunr�ruc/t' Office of Consumer Affairs&Business Regulation ,HOME IMPROVEMENT CONTRACTOR Registration: 176626 Type: Expiration: 9/10/2017 DBA EMERY CONSTRUCTION BRETT' EMERY 19 KELLEY RD SALEM,MA 01970 Undersecretary 0 CITY OF S UJU_N� KUSS ACHt,SET TS 120%V.AS14LNGTORi STi=7 3�FLOOR TE-7 (978) 79.5-9595 R a X(918) 740-9844 K1NfBERL_VY DRISC-07 7 DIRECTOR OFPUBPICPROPtA2:r/BL: ZI.SGCONndiSSIO:dE1 Workers'Compensation Insurance Afd$avit: �t�aides§/r¢tlEeras2erJ�Hea4risianJ��€a€�e�er� A13 iicant 7nfurtnatior / T Please Prin2 Leviesi/ Natlie (Businey organiZatiowfndtvidual): Address. lei tcel car fZ�) City/State/Zip:_ /?.� /v 4 rsLL)Cphone it: 7g ' © Z&ka Are you an eimployer'Check the appropriate Dos: Type of project(required): I_N l am a cmPloycr wiut :r _ 4. [1 1 am a general contractor and i d-1 employees(fall and/or pact-time)." have hired the hub-contractors 6' E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7. 0 Remodeling ship and have no employees These sub-contmoeors have S. C]Demolition working for me in any capacity, workers' comp.insurance. o [No workers'comp.insurance 5. 0 We are a corporation and its - 0 Building addition required-] officers have exercised dwir 10.0 Electrical repairs or additions 3.Q 1 am a homeowner doing all w'orik right of exemption per MGL 11.0 Plumbing repairs or additions myself(No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)r etnployeas.INO workers. comp.insurance requiseld.] 13.0 Other 'Any anpldtrnf that checks hoz 31 must also fill out the section imlow 51topung their u' rken'coo `oration policy mle r ILtmenwavxs who submit this affidavit indicating the,,ace doing all wort[and then hire oulsidc cmumctors must submit a nets afrdavie indicting such -r]mtmotors that chick his box most anzched an additional ahea showin rte nation of th S .e subannuaetors and their wotkrra'eomy policy information. r am¢p empio,eP that is pPavtdarg 10arlkers LamryCiiSQrtaAE tr1SQPaaCC far my ampioyees. Below A flee policy and,/ob slec, Insurance Company Name:_ ACIVG,Y /X-7-4) Policy#or Self--ins, Lic.k: S r-C Expiration Date- Job Site address: 'tttzcCity/StatclZip: Failure a softy a ovthe woriseas' eompen5adioo po]icy fie" Page(showing;tine palicy number and expiration elite). Failure to secure coverage as required under Section 25A of MOL c_ 152 can lead to the imposition ofcriminal penalties of fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the R and a Fine form of a$TOP WORK ORDER up to 5250.00 a day against the violator- fie advised that a copy of this statement may be Forwarded[o the Office of Investigatiuns orthe DIA for insurance coverage veriticution. o.,hereby certtjy ter Ute pains ora reaalties o er' - ! jp yQPy ibat f/le iVOratvfioet pro:+idud,above is rrwe erre#eo,r(, �ionatnre: ,�/" Phone n: 9,7 OJ clal use 01111c Teo not write i+a fills erea�to be canrpleted by city op toton afy ia( Circ orTnlvn: issuln authored -- --- "-7spector{circle ane):1- Board of tieolta 2. nuilding department3.Cityf[�a1Yn Cler's d.Electrical InspeUor 5. PtnB 'Contact Person: I - - - Phone ii: i o %,I—I Y OF SAUEN e IXL- SS'kCH SEAS 68 B'U9LDU4G DEP,Pt=.aLFNT W.zsxr-Nta=1o;v ST_ , 3�boob 7 a (978) 745-9595 Kimmm..Y 13RISCO"E 5'°.A,,-{978) 74WW AyJL-f`lr�•'.�}sS �=F'.�;v�eC'3 n.l'�s".`�,1� 1-11mic-ior,aF FL;mIo,pR0pERT'x/Ei;ao1-, C_Ca% llssav-EER Construction Debris Dnspuosai Affidavit (required for a1_1 demolition and renovation work) fn accordance with the sixth edition of the State Building Code, 790 Cl%AR section 111.5 Debris, and the provisions ofG—T e 40; e 54, Building Permit# is issued with the condition that the debris resulting frorl this worlc shall be disposed of in a properlg licensed waste disposal facility as defined by 7vIG1 c I11, S 150AR The debris wi Il be transported by: 2-7 fnamc of hauler) The debris will be disposed of in --- (name of facility]- (address cf;aeiliiy sigttatureofp rmitapplicant Jafi J,itnsall.Juc