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14 HIGHLAND AVE - BUILDING INSPECTION
167 The Commonwealth of Massachusetts i Board of Building Regulations and Standards CfrY OF Ij Massachusetts State Building Code, 730 CMR Revised LE�.110!1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This SectionF ,ficial UsaOnf Building Permit Number: Data Applie, , 1` Budding OtFcial(Pant Nat $ign ra ate SECTION L•SITE INFORMATION ` I.1Y59Pert 117,4NO �y� 1.2 Assessors Map& Parcel Numbers x l.la [s77thisffa77n�s acce tad street?yes no htap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions. Zoning District Proposed Use Lot Area(sq tt) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided " 1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Cheek if es❑ S1 CTIONZ:; PROPERTY'OWrM I1Pl'':' 2. Owner[ofRecor : >�i)sjr4L6 C- Alel--k,R -! /W-em MA 2192e amen (Print) City,State,ZIP No.and Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED.W0RK1'(check all that apply) New ConstructioAf Existing Building❑ Owner•Occupied ❑ 1 Repairs—w ❑ 4lteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed %Vorkl (}(` SECTION 4: ESTINLATED CONSTRUCTIONCOSTS frem Estimated Costs: Official Use Only,:. Labor and Materials L Building 5 �� 1..Building Permit Fee.S` indicate how fee is determined: r Flacrrical g ❑Standstd.City/Cutv[rApplieation Fee.' ❑Total Project Costs(Iternhi x multiplier x ). Plumbing S �. Other Fees: $ 1. ,Mechanical (IIVAQ 'S List: i. ,Mcchauical (Fire i , ires,:on) 1'utal All Pees:.S Check No. Cheek Amount— -- C;ish :\uwnnt / I'utal Project ('nit: S �7 �zj u P.:i l in Pull ❑t)utstandim" Balance I)u : --- {4 o f sEC'rION 5: CONS'fkUCl'[ON SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Data Name of CSL I louder List CSL Type(see bale rype Description No. and Street U Unrestricted Dui 'n s u to 75,000 cu. lt. R Restricted 1&2 Faint Dwell in city/rown, State,ZIP VI \lasonr RC Rootin Coverin , WS Window and Sidin SF Solid Fucl Burling Appliances I Insulation I'ela hone Email address D Demolition 5.2 Registered Home Intpr vement Contractor(I11C) tIIC Registry 'on Number Expiration Uate I IIC Company Name or MC Registry Name No.and Street trail address City/Town,State 'LIP role hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 25C(6)) Workers Compensation Insurance a av[t must be completed and submitted with this application. Failure to provide this affidavit will result in the denial o Issuance of the building permit. Signed Affidavit Attached? Yes.......... _ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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 Hama(Electronic Signature) Data SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. I Date dd 11 Print Uwncr'3 ur r�lllhUflLCd:�,M,ellt'i N,II11C(•Icctruniu Signature) NOTES: I. .kn owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(H[C) Program), will!lot have access to the arbitration program or guaranty tund under ALG.L, c. 142A. other important information on the HIC Program can be found at w tNV IInl33.L'l10'%Ueq information on the Construction$llpervi3or I.Icense can be found at ww\y.I1Y155.�ILL 2 When substantial work is phutneJ,provide t to information below: (including gartga, tinished haselnent/attics•decks or purch) rural fluor area(sq. lt.) (iNi; living arca(sq. It.) __ Habitable nluut OMS _ Number of tiroplaces, .--.------ Nubmber of hedrooms -- ----_-_-- --_----- Numberofbathrooms _. _----- Nnntberot'deckbaths _-- - f.peofhaatinq ;yitellt Nuutherut.(ecks'puriltes .._. -.-- --_--- --- --- Enclosed pen _ , I\hC ill iJolllh iy.tClll I. "I 'r.d lit,q:Ca ",yu,u'c P„ol r,t'•w.ly he ild"litnt: l � I( CITY OF SM-EIM PUBLIC PROPERTY DEPARTMENT vnra t]e s�sr,K,�on arsaaR•i�a4 wobw Lcm at s-s Mt.s-0.7654sss v.a r.s•7+sasw HOMEOWNER LICLNSB EXEMMON Please Mat Dam / i3 Job Location Home Owner Addrrar Home Ownw Telephone d Pmaaot Mailing Addron L The current exemption of'Womeownere was extended to inchtd@ owner-occupied dwellings of two Units or fees and to anowr such homeowners to engage m individual for him who don not poaaass a ticenso provided that that owner acts as supervisor. DERNMON OF HOMEOWNFA Pawn(p) who owns a parcel otiand on which WAS resides or Intends to resider. on which there i; or is intended to be, a one or two fat ily dwelling, athchad or detached structures accessory to such use and/or farm structure, A pawn who comtructa more than one home in a two year period shall not be considered a homeowner. Such 'homeowner"shall submit to the Building OQlciA on a form acceptable to the Building OiTHciall, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeownee asnunce responsibility for compliance with the Stu@ Building Code and other applicable by-laws and reguladon& The undersigned "homeowner'certifies that hNshe understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she Mill comply with said procedures and r u cm to HOMEOWNERS S1GNAIT.RB .APPROVAL OF BUILONG OiSPEC7'OR � See Other side far itate code ;. CITY O F S.1.(.E,1 . [ uL155aCHLSE� ' � TTS �� Qt:ttntvC D i 1'V.13JiLYGTO,V 3TUrr 310 FLOOR r L(979) 7s5-9593 XIMOEM PSY MUSCOLL F�-X(973) 7•10-934,$ ,bLILYO;t 'Gio usrPIERM D(1$CTO R U F AC OLIC PROP ERTY/8 C lLD 4�1G CO�Ll tlSstON[sR Construction Debris Disposal Affidavit (required tot all dcmantlun and mnuvation%York) fn accurdanca will% tha sixth edition of the State Building Cada, 730 Cj%fR section I Ocbris, -u%d the provisiuns of tWGL a 40, S 54; ©is%vu g Pershall b* is issued%vith the condltlon that the dcbrfs rasulting from t 4 111 wuJ shall be disposed of in u pruperly licensed waste dlspasal rauility as defined by NfGL a t l I, S l 50A. Tho ddduhtis will be transported by: Al V-ev,9—Nejr (nama uChaula�) The debris "ll ba disposed Of in : (nnma at licdit�) iI /117 i•puiurc (permitut iauit 1 � � f 9 �4 J �J x k Y h Jf All sk Lkk m >Yr { ,t ha,n Z _ ,.4z.< •ru�.v. y TWO n "5y..r¢••' ' ON Ail I � � ll a c�