42-44 HIGHLAND AVE - BUILDING INSPECTION 25 -0018 - 0 2 5 �c���� A�%Ca �� 13
"file Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�f Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official'Use-Only
Building Permit Number: Date Applied: ' "
ec-1y 13
Building Official(Print Name). Si afore - Date. _
SECTION 1:SI
I.I Property A dress: 1.2 Assessors Map& Parcel Numbers
x yZ -uu l� tilar, � A,oe
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
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 ❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP`
TZt Owner of Record, `
I ' Of` P OY�`f-t �\mow., ft^1a... (5 i Qi 7 O
C „ - me(Print) City,State,ZIP
Lt
No.and Stree '� 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
CO .n— r+7Y\� nSs P nl✓r- R-Cl's7 __ _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List
5. Mechanical (Fire $
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: < COO ❑Paid in Full 0 Outstanding Balance Due:
x
SECTION 5i. CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL"type(see below)
No.and Street Type, Description' .
U Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Nlasonry
RC Roofing 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: 152.4 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 is$uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containSdiuJiLis applicatio o the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mnss.govoca Information on the Construction Supervisor License can be found at
www.mass.so�;4lps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
I
CITY OF S.ULE.tif
PUBLIC PROPERTY
DEPARTMENT
V/43LY/Y ONNUYL
w+v t b V.ww,,on stn..r•Su04%(MV C a WM as s-e
HOJ� EOUNER LICELAIS6 E.XE.M"101*4
Date 8— 1ln' Zi7C
lob [."tics `-l2 - 14 k
HomeOwmwAddress IsZ
Home Owner Telephone �- A L,
Precool Mailin$Address 5 - 1-k z1-.\Q -. a4 �a \P., N.a O19 21
The cumot exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or tee and to allows such homeowners to engsge m individual for
hire who.don not poamm a tkeas4 provided dial the*woos acts as aupwvisw.
DEFINITION O/HOMEOWNER
Person(.) who owes a parcel of Lad an wbkb hahhe resides or intends to reide, an
which there Is, or is intended to bey a one or two fmWIy dweWng, attached or detached
structures mceswry to ouch use mWoe[um otcuctunes, A porme who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeownel'shall submit to the Building OQlcial,ors a form acceptable to the Building
OtPicial, that helshe be r"1. , rme
rivible for all such wort Performed under the Building
Pamir
The undersigned "homeowner"umnes responsibility rot complimsce with the State
Building Code and other applicable by-laws mad regttladom
The undenigned "hameowrice certifies that helshe undentands the City orSatem
9uilding Department minimum inspection procedures and requirements and that helshe
.vill comply with said procedures and requi
HOS1EO WYERS S[G.JA TL'RB
APPROVAL OF 9UILD[.VG 1.VSPECTOR
See other side for state cods
•x.
CITY OF SALEM, NLksSACHUSETTS
Bum tzNG DEriRTMEVT
120 WASHINGTON STREET, 3AO FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
Kl,,{BFRt EY DRTSCOLL
A&A'YOR THO.%tAS ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
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 wilt be transported by:
(name of hauler)
The debris will be disposed of in
_�--_— (name of facility)- �_-
(address of facility)
signature of permit applicant -�
2c'� l3
4 date
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