25 HIGHLAND ST - BUILDING INSPECTION C,K 1 u z0 $qq
44 The Commonwealth of Massachusetts G IL 3
9, IPbSPECTIOl�a�L ��'Fbt/4�•ES
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR yplS �(�u Rev d. ar Il
Building Permit Application To Construct, Repair, Renovate Or DdtMlttlis'It'd b �
One-or Tivo-Family Dwelling
This Section For Official Use On!
l Building Permit Number. Date
Dat _pplfed
Si maro '
.- - ... .
P
Name).
Building OlTicial Tint ..
(
SECTION l:SITE INFORMATION'
1.1 P perty Address: lG Qi s .2 Assessors Map�Parcel Numbers
�r' 1-7
I.la Is this an acce to streetl yes no Map Number Parcel Number
1.3 'Zoning Information: I. roperty Dlmeastons:
2 ing.D� Proposed Use Lot Area( y it) Frontage(11)
LS Building Setbacks(R)
Front Yard Srde Ywd+ Rear Yard
k0inivJ Provided Req I Provlded I Required' Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Informatloni 1.8 Sewage Disposal System: `
Zone: _ Outside Flood Zone? MunieipW O On she disposal system O
Public O - Private O. Cbedc If.est ,--
SECTIONZ: PROPERTY,OWNERSHiP!
2.1 ner'ofRecord: —DGEI�/�Cz �U ef, leLc2 D
tWne(Print) City,State,ZIP
/2 �O/2L=LSA^ Ro 79;31�93Y2
No.and Street - Telephone Pmail Addnas
SECTION 3:DESCRIPTION OF PROPOSED%VORW(check all that apply)
New Construction O Existing Building O owner-occupied O Repairs(s) O Alterrtion(s) t] Addition O
Demolition . a AccessoryBldg.O Number of Units_ Othw O Specify:
7 Brief Description of Proposed Work=: _ Dd
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itcm - Estimated Costs: official Use Only
Labor and Materials
I. Building S i, Building Permit Fee:S Indicate how fee is determined:
❑standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost!(item 6)x multiplier x
3. Plumbing S J?Qther Fees: S
d.Mcchanical (FIVAC) S List:
5.Mcchanical (Fire S Total All Fees:S
Su ressiun)
Check No._Check Amount: Cash Amount:
6.' tal Project Cust: S ❑Paid in Full ❑Outstanding Balance Due:
MAtt_Eo -11:) N • o . (( z3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date-
Name of CSL[folder '
List CSL'fype(sea below)
No.and Street - Type. Description .
U Unrestricted(Buildings upi to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofina Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tele hone Email address D I 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
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e:152.§ 25C(6)y,
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isluance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN',
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDINd PERMIT'
I,as Owner of the subject property,hereby authorize
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nano(Electronic Signature) Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of peq'ury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
,804 �' Cz 1,1111611S -
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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,impro __ -
program or guaranty [land under M.G.L.c. 142A.Otherimportani mfeima[—fon on the MCProgram can be ot alt- -- — —
wsvw.mass.eov'oca Information on the Construction Supervisor License can be found at www.ntas� .
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. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'fype 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"
aQTY OF SALEM, MMSACHUSETTSBUILDING DEPARTMENT120 WASFENGTONSTREET,3" Flom
TEL. (978)745-9595
KIMBERLEYDRISOOLL FAX(978)740.9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 6 / J ,/�.
Job Location_ /��%rI Az a1,7ey J l� SGy/�� / �/�
Home Owner Address
Present Mailing Address 2 s- f— l g!/�U[ o--?C)/
i
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 requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE /
APPROVAL OF BUILDING INSPECTOR
C r7 Y OF SALEA MASSACHL SEM
B[wiwDEFAmwNr
120 WAStDNGMNSUM,9mFLOQR
7LL(978)795-9595.
PAX(978)790.9846
%IIvJ6ERiEYDRISQ7LL
MAYOR 7)KWesSTY MBE
D=Ecrca of Pu&ucPROPERTY/BI HIDING oomm=omR
Construction Debris Disposail Aff1davit
(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 e40,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.-
(naVre of hauler)
The debris will be disposed of in:
Wme of facility)
(address of facility)
gn u of applicant
Date