1-11 COUNTRYSIDE LN - BUILDING PERMIT APP h
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised Mar 2011
r Building Permit Application To Construct,Repair, Renovate Or Demolish a
1 One-or Two-F Dwelling
This Sect n For' fficial Use Only
Building Permit Number: . (/J to Applied:,..
Building Official(Print Name) nature Date
SECTION 1: SITE INFORMATION _ 5,
1.1 Property Address: 3-25 Olde Village 12 Assessors Map& Parcel Numbers
1-11 Countryside Lane 03-0006
1.1 a Is this an accepted street?yes no Map Number Parcel Number „—.(- _
1.31.3 Zoning 1.4 Property Dimensions: �7O-J-1.91F
A(-) 4a• 3 - �v
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY,OWNERSHIPI,,
2.1 Ownert of Record:
HIGHLAND CONDOMINIUM AT SALEM
NaTbTint)IGHLAND AVENUE City,State,ZIP
AH 978-741-2003 EastCoastPrW1 aol .com
No.an treet Telephone Email Address
SECTIONS:DESCRIPTION OF PROPOSED WORK2(check all that apply).
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use'Only
(Labor and Materials
I.Building $ 2 5 000 . 1. Building Permit Fee: $ Indicate how fee is determined:
tandard City/Town Application Fee �
2.Electrical $ -0- a t otal Project Costs �(Item 6)x multiplier 5 x
3.Plumbing $ —0— Other Fees: $
4.Mechanical (HVAC) $ —0— List:
5.Mechanical (Fire $ —0— Total All Fees: $
S5 ression
Check No. Check:Amount: Cash Amount:
6. Total Project Cost: $2 5 ,000 . El Paid in Full "❑Outstanding Balance Due: '
SECTION 5: CONSTRUCTION SERVICES "
5.1 C n truction SupervisMdezLigzn
se(CSL)
_ e
� ��/T License Number xpiration Date
Nle o^fff�SL Holder M as �2,p List CSL Type(see below)
No.and Street Type Description
a�/��p n/ U Unrestricted2 Family
(Buildings u el ing cu.ft.
,�/ /I--/ l�'�(/ R Restricted l&2 Famil Dwelling
City/Town,State,-ZIP
M Masonry
`" /�✓C�/ RC RoofingCovering Win
WS Window
andSiding
d
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
SECTI,ON 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§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 -Y— 1... ❑ No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR MILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act onmy behalf,in all matter relative to work authorized by this building permit application.
6
Print wt er's Name(Electro to Signature) Date
SECTION 7bi OWNERr OR AUTHORIZED AGENT DECLARATION
By entering my name bel 2�'�
by attest under the pains and penalties of perjury that all of the information
co ed in this appli tioand accurate to the best of my knowledge and understanding.
' —/
r'n er's or Author A ent'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 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. ove /oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
P
CITY OF S.UEINI, 1UNSSACHUSETTS
BUILDING DEPARTS ENT
120 WASHINGTON STREET, 3�FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\{BERT RY DRISCOLL
MAYOR THows ST.MRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJL%aSSIONER
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
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(names of f��li
(address of facility)
signature ermit applicant
date
and,Jtrao<