56-58 HIGHLAND AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
t Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'n edition OF SALEM
"'www Revised Juntrury
Building Permit Application To Construct, Repair, Renovate Or Demolish a l• 201AV
�p One-or Two-Fumi1v Dwelling
c� This Section For Official Use Only
Building Permit Number: Date Applied: e7
Signature: Z�
Building Commissioned Inspector 6f Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.1 a Is this an acca ted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arta(sit 11) Frontage(11)
1.5 Building Setbacks(R) _
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 Dbposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
s Lo t'l-i ZocNF✓xct.E 56 —Sff )4Z-rl+(~b AVC—
Np (Print) e-� Address for Service:
Jc � /1 C1,7S Ze7. 5� ro
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ I Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units %t- Other 9 Specify:ST-D=kLCG
Brief Description of Proposed Work': ZCvtAOy)c cL.a V--WVL pulp fl3PLY
140%kS& LX - eePtAc£ iLyoFMPc SosH[-LS cra nAuo 0Lyc*AA .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofliclal Use Only
Labor and Materials
1. Building S iS o ,Oo I. Building Permit Fee: s Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (NVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full O Outstanding Balance Due:
I
e !
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
l.iccnw Number Expiration Date
Name of CSI.- I hdJer t.isi CSL rype(see below)
r Dexri ion
Address U unrestricreJ u to JS,000 Cu.Ft.
R Restricted 132 Famil Uwellin
Signature M M Onl
RC Residential Ruufin Covering
Telephone WS Residential Window and Sidi.
SF Residential Solid Fuel RunningAppliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
f IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 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 ..........O No...........O
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.
SijtnatumofOwncr - Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
S sATC E
Print N {pe , p
Signatured\1.of Owner or Authorized Agent Date
(Shined under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 IO.RS, respectively.
? When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"
CITY OF S.U.E.NI
PUBLIC PROPERTY
DEPARTMENT
w,�arsv�•• •�
AAYoe t 30 WA9uw.7CN snrsr 9 ImAK%&uA0jL= S 019'0
YVL r11-7+5`9S"• P.uL 978.740.9e4e
HOMEOWNER LICENSE EXEMPTION
Plesse Ftrist;;
Dam (a s l o
Job Location 5 U -St' r+z"t_A h A k.JG
Home Owner Address s nnE
Home Owner Telephone `II g `16l 6 6-70
Present Mailing Address s,,rv1
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION 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 form 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 undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures requir ter
HOMEOWNERS SIGN RE ATU
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
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',�:'I PUBLIC PROPRERTY
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DEPARTMENT
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A I IN S IR I:1 T 0 NAI I M. %I\Ii\t :il <i 1 , _I1 _
lrl: '/7y-'�i.9i4j ♦ I'\s: '/'%Ja}'lfiali
Construction Debris Disposal Allidavit
(MlUired lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
�Rzc Z ba&posA-L'
(name of hauler)
'I lie debris will be disposed of in
(uamr of facility)
(address of facility)
signature of permit applicant
date -----
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