56-58 HIGHLAND AVE - BUILDING INSPECTION (2) CITY OF SALEM
An PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cb1R 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 v1GL c
111, S 150A.
The debris will be transported by:
;F,<.zG Z _
t name of hauler)
The debris will be disposed of in
_ (nafrne of facility)
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CITY OF S.XLEM
PUBLIC PROPERTY
DEPARTMENT
Vnraa 13ow,mu�o�+sti,um•�.^Mwtuon.•seTtS01970
TEL 97674S-9S9S* FAi:978-740.96"
HOMEOWNER LICENSE EXEMPTION
Plea"Print
Date LIB //off'
Job Location SG - 5 e H.CGNtAAaD 4 VE
Home Owner Address 5 tr-S k 4T-&"%-AMD 4V E
Horne Owner Telephone 9-78 16-1 S�'► C
Present Mailing Address 5 U -S S H=c.N L-AN D AVE
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 who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 fora 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
The Commonwealth of Massachusetts FOR
L Board of Building Regulations and Standards MUNICIPALITY
R ' Massachusetts State Building Code. 780 CMR. 7ih edition USE
Building Permit Application To Construct, Repair. Renovate Or Demolish a Revised Junum:v
One- or Two-Ftu tily De•elling 1. 2tx)3
Tlus Section For Official Use Only
Building Permit Num Date Applied:
Signature:
Buil ng Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Add re / N` Q 1.2 Assessors Map & Parcel Numbers
1.to Is this an accepted street?yes_ no Map Number Parcel No nher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use tut Area(sq fl) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.1.c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record: ItSGHcAAJb Ay(:
S"ce•tT QoC NEJit_t-E
Name(Print) Address for Service:
SCA� VI s yi o
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin&X Owner-Occupied. I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Z I Other ❑ Specify:
Brief Description of Proposed Work=: NEB Slte-ET teocteL b14CO PA= AP6ATE B4-r14s o6n,&51 usreµFnr
(Ae1fo-reCTo? CA�KPE-T; T'S%-E 4P�000—/ SOME REP[.thC6M6N'r wStvovw&
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ ppp, o0 1. Building Permit Fee: $ Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. + dU
' eck Amount: Cush Amount:
6. Total Project Cost: $ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL• Holder List CSL Ty
pe(see below)
Address T Description y
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&_' FamilyDwelling
Signature M Masonry Only \\
RC Residential Roofing Coveringl
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Bunning Appliance Installation
D Residemial Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
\ SECTION 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
\V this affidavit will result in the denial of the 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.
Signature of Owner Dace
SECTION 7b: OWNER' ECLARATION '
LG ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name � _ t n I Or
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basementlattics,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"