23 HIGH ST - BUILDING INSPECTION /1 YI The Commonwealth of Massachusetts
U'JJJ —I. Board of Building Regulations and Standards CITY OF
1 Massachusetts State Building Code 780 CMR SALEM
1 g Revised tL1ar 2011
Building Permit Application To Construct, Repair, Renovate Or Demof a
One-or Two-Family Divelling
This Section ForOttic at UseVnly.
Building Permit Number>;'.- Date Appit`
Building Official(Print Name) Signature.,; Date
SECTION I-SITE INFORMATION
1.1 Pro erty Address: LZ Assessors Map& Parcel Numbers
1.1a Is this an acee6ted street?yes_ no Map Number Parcel Number
1.3 Zoning Information 1.4 PrMl)i ensions:
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 Wate/r.Supply:(M.G.L a.40,§54) 1.7 Flood Zone Information: 1.8 Sewage tsposal System:
Ig Public Private❑ Zone: _ Outside Flood Zgae? Munlc(pal On site disposal system ❑
Check if yestir
SECTION
Zc; PROPERT$'OWNEISHIPL
2.1 Or (Reco : 410, L
( r O
Name rint) City,State,ZIP
c gs 917 fare
No.and Street Telephone r' mat Addr s
SECTION 3: DESCRIPTION OF PROPOSED WORIO'(check that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) fiYj Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description ff Pro sed Work":
ov el
SECTION 4: EST INIATED CONSTRUCTION COSTS- .
Estimated Costs:
Item Official Use Only-...
Labor and Materials
1. Building S p I..Building Permit Fee.S' indicate how fee is determined:
❑Standatd.City1 utvn•ApplicationFee.
?. Electrical S
q'Cotal.PiojectCast .(Item.6):cmultiplier x
3. Plumbing 5 2- Other Fees: S
t. Mechanical (11VAC) S List:
S. Mechanical (Firs 'Total:\1! Fees: .S
Sii ression) — --
Check No. Check Amount: __Cash :\mount•.
I'ufol !'reject Cost: 5 740 / I U Paid in Fill[ ClOutstanding Halance OuL!
� r
SEcrION5: CONS"fRUCI'ION SERVICES
L51. Construction Supervisor Liecuse(CSL)
� 4V �p 2
� 1Gf ��r� �__ License Number Expiration Date
e of CSL I told / r List CSL Type(soe below)
I Type Description
No. and Street
U Unrestricted Buildings up to 35,000 cu. a.
R Restricted 15d2 F;unil Dwellin
City�n, State, ZIP Nf %-Iasonr
RC Rootin Cuverin
w
M Window and Sidin
GO�/ki SF Solid Fuel Burning Appliances
9��J Zk: TZ I Insulation
1'cle hum C
> Email address U Demolition
5.2.-R-�egistered Home InIWProvemenent Contractor(H C)
FIICRegistrati n er Expirntiun ate
111C Compan ame ur I1IC Registrant M ne
No.and Str 6 Email address
�� z 1>9�a ��
ni�66 �7�. ���:
Ci /To n,State ZIP Telephone
SECTION 6: WORKERS' COMPENSATIO INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuano of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION In: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION IN OWNEW OR AUTHORIZED AGENT DECLARATION
;entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
n this application is true and accurate to the best of y knowledge and understanding.
s or r\uthuri • Agent's Not Else uc i aura) Date
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Iionte Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty rund under \LG.L. c. 142A. Other important information on the,[IIC Program can be found at
www m;us.euv/oca Information on the Construction Supervisor License can be found at w�ew.mas .,y±v_dles
3 When substantial work is planned,provide the information below:
Tot:d floor area(ml. 11.) __—__ —(including garage, finished bascmentlattic.s,decks or porch)
tiros; living area(sq. III — Iiabitable room count _
Number of tireplaccs_---- ----- Number of bedromns
Number of bathrooms Number of h;tlubaths --_-----
fcpu o 'haating ;yatcut Number of deck.,' porches
— ---- --_. -- -----
\peol'Cooling ;yacitt __.__. . Fincloscd. -- _ open ---_---._ --.._
•' , I ttl I'r,iiccl Co " '
� I. `I„tat I'nq,rt Syu.u'a I�nn�.i,a may Ilk: sub;tuut:� t;,r"I"�� . - - i
CITY of S.u.E4Ni LbWs:
lCHU5ETTs
v
`1 t BUDLYGDEPm-mLE.rT
.3 l20V/-" C4GT0V5MIT, 3°'Rom
TEL (978) 743-9595
!Q.J(OFRLEY DRJSCOLL F+ t(973) 7-W-934,5
,bUYOR CFl01t13 ST.PIEAAB
DLIECTOR OF PLOLlC PROPEA7y/BCLLDL4G COSLMISSIO,NER
Construction Debris Disposal Arildavit
(required for all demolition and rcnuvation work)
In accordance with tlla sixth edition of lite State Building Cade, 730 CM Section I t LS
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this wutfC15 shall be disposed of in a properly licensed waste disposal facility as defined by 4'v1GL a
l t 1, s l sna.
1'I1c debris will be tr�ansporttcd"by; /
(Hama ot'haulur)
The debrii Mlll ba disposed of in ;
(name ai t'.m,lily) /
o�
(,dd 71, ur racil,l%)
i�snan}� ot'permit.rpp ic.tnt
S [ ay*•e�'e 4 ♦ .ex, -. + N• k F'wc wp }i'''{ "*x 'x•P tt� JSWi s 5 '.'r^f rG r, y,�r.�
CITY OF S�UY_,11ri, lILSS.ICHUSETTS
BL'(I.O.NG.DEPiIiT\IE.�iT
120 WASHINGTON STREET,Ya FLOOR
TEL (978)745-95915
F.ix(978) 740-9846
KI.,fBER3 EEY DRISCOLL
MAYOR THost tis ST.Pwmns
DIRECTOR OF PUBLIC PROPERTY/BURMING COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/E►ectricians/P.lumbers
Applicant information Please Print Le ibiv
Name(Business:Orpnizationllndividual): O
Address: d Ai✓G,p2 �� l��U
City/State/Zip: eAwO 76 4Phone#: 77 9Qf To J T
Are you an employed Check'the ppropdate box:
Type of project(required):
I.❑ 1 am a cmpio ciwithr 4. ❑ I am a general contractor and 1 6, (� etti construction
e loyecs(tftll and/or part tuna).' have hired the Subcontractors ..
2., l atn a sole'prapnetorurpanncr listed on the attachedsheii10 y G✓ Remodeling
shipandhavernoemployees , , Thcse,sub-ctintractorshsva 8 ❑Demolition
working;,for me in any capacity: workers'comp insurance q ❑building addition
(No workers'comp. insurance 5. ❑ we area corporation and its:
required:)" officers have exercisea their; 10❑Eleotrica!repairs or additions
3.❑ 1 am a.Homeowner doing all work right of exemption per iNGL. , i I.❑Plumbing repairs or additions
:myself.,[YoworkersScomP. C.,152,'§1(4);andwehsveno _ i2.❑Roof>cpaira:
msumitca requred.)t employees:(No workers'', 13 ❑Other`;
-r_ comp:inwrnnce requiredlJ
•Any appilwal that chicks box st must also fin uut the section below showing their worker'compensation pansy mrumiotton:'
I hxneowncrs who submit this ifndavit indicting ih y sni doing all work and thaa hlic outsido contrneeors must submit a new onidavil indicting rush
Cnnuautors that chickthia boll most onxhe4 an addiaurml sheet ihowin IhO naneoftM sue e3husi som ind the4'workm•;comp;policy informonon:..
s
lain an employer that bpraVlding workers'rotapr'rriadelei
nsurance for igy'einp(uyees:'"Bel, 1. he poilcy and fob sib
iirjormurion , .r ra .. >_,
Insurance Company Name:
Policy,4 ur Self-ins.Lic,e: Expiration Date: '
lob Site Address: ®;3 _/7/ h !11�� Ciry/Siatcaip:_�i l
Attach a copy of the workers'co pensattaa policy declaration papa(showing the policy number and expiration date).
Failure to secure coverage as required tinter Section 15A of MG[s'c. 152 can lead to the imposition of criminal penalties of a
tint up to S1,500,00 anJlor one-year imprisonmcn4 is well as civil penalties in the forni'ofa STOP'.WQRKORDER and a fins
of up to S250AOp Jay against the violator. 13e advised that a copy,of this statement may forwarded to the Office of
Investigations of.iltu DIA for insurance coverage veriFcatiun.;
Ida hereby certify tinder the pain�d peualries a prrfury that the injornrurlon provided above is true and correct
o 4: ,
Offrcid use only. De not write in rlrir urea,to be cuarpiered by city or town aff elaL
City or'fown: Permit/iJcense#
Issuing Authority(circle one):
1. Board of health 2. Building Department J.Citylrown Clerk 4. Electrical Inspector 5.Plumbing inspector
6.O1 her
._
Contact Person: __ ____ Phone#•