0400 HIGHLAND AVENUE - BPA 861-12y
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 70]1
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:
f
bat
b
e Applied:,
BuildingOfficial(Print-Name) Signatur Date'
SECTION 1: SITE INF MATION
1.1 Property Address:1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street9 yes tZ-no Map Number Parcel Number
Y" 1.3 Zoning Information: 1.4 Property Dimensions:
j
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private
Zone: _ Outside Flood Zone?
Municipal n site disposal system
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor
Name(Print) City,State,ZIP
No.and Street Telephone Email Address Aa
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied 194 Repairs(s) 1 Alteration(s) Addition
Demolition Accessory Bldg. Number of Units I Other Specify:
Brief Description of Posed Work 2:
V
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use OnlyLaborandMaterials)
1. Building 1. BB Ming Permit Fee: $ Indicate how fee is determined:
95t dard City/Town Application Fee -2. Electrical otal Project Costs(Item 6).x multiplier A10 x - /
3. Plumbing 2. Other Fees:.$,
4. Mechanical (HVAC) $ List;.
5, Mechanical Fire
Suppression)Z- Total All Fees.$
Che k No./61f50 Check Amount: ' r Cash Amount:
6. Total Project Cost: $ (/JU i(1 G, Gyl'aid in Full 00utstanding Balance Due:`
SECTION 5: CONSTRUCTION SERVICES
L''L
f5.1C onstruction Supervisor License(CSL)
E"Ji<> S' License Number xpiration Date
Neme of CSL Holder
List CSL Type(see below)
No.and Street
V/ ,y d
Type Description
41 jI ey_d U Unrestricted2 Family
Buildings u
el ing
cu.ft.)_
i l/ d" (/ R Restricted 1&2 Famil Dwelling
City/Town,Statue,ZIP M Masonry
33 J / J J
RC Roofn Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 A P7PLIES FOR BUILDING PERMIT
I,as Owner of the subject property. hereby authorize 2Y
to a my behalf,in all ers r lative to work authorized by this building permit application.
y
P rut n s Name(Electro gnamre) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below - e eby attest under the pains and penalties of perjury that all of the information
co71n/in this applicat' n is I*and accurate to the best of my knowledge and understanding.
P nt O ne s or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass. ogv/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) including garage, finished basementlattics,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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
LIZ, Ofrce! oasumer'' 1hs&Vness ffego(ujon& License or registration valid for individul use only
V.4
HOME IMPROVEMENT CONTRACTORbefore the expiration date. If found return to:
Registration 149839 Type: Office of Consumer Affairs and Business Regulation
Expiration 2/13/2014 DBA 10 Park Plaza-Suite 5170
CU,
Boston,MA 02116
MERRIO CONSTRUCTION
MICHAEL MERCURIO 7
127 OAK STREET
WAKEFIELD,MA 01880 Undersecretary Not valid without signature
vjassaCluisetts- Department of Public Saf'vh
Bo::rd or Building Re-ul:uions and Standards
Construction Supervisor License
License. CS 91942
MICHAEL L MERCURIO
127 OAK ST
WAKEFIELD, MA 01880
Expiration: VV2013 .,
o...... loner Tr#: 9263
CITY OF S.U.E,tii, INLkSSACHUSETTS
BuIIDLNG DEPARTMENT
130 WASHiNGTON STREET, 3 FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
g1NfgRRt RY DRISCOLL
1AYOR T1i0AfAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONL,IISSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
name of hauler)
The debris will be disposed of in
name of acility
address of facility)
signatur permit applicant
date
nd,n.auc