56-58 HIGHLAND AVE - BUILDING INSPECTION cw- z-S,7 3 z-s
Aa The Commonwealth of Massachusetts RECEJR
Board of Building Regulations and Standards INSPECTIDN91C'ESIF
Massachusetts State Building Code, 780 CMR SALEM
sed,('l it 2011Building Permit ApplicationTo Construct, Repair, Renovate Orjl�nS6Ph hK L
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied.
Building Official(Print Name) Signature Date
SECTION I:SITE INFORNIATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
K 56--rA ArG�FLA.cI1J q-(/E -
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Usc Lot Area(sq fl) - Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NLG.L,c.d0,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. wner'of Record:
�c OoTr� oc,4£I/7'L
Name(Print) City,Sane,ZIP
54? H`rC-FFLr4A11J ,4rE_ 1797✓o7567a SQvt�fEvrccE�J eo n c r, �T—
No.and Street 'Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ E.xisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:__
� l Brief Description of Proposed Work'-: 7r� e��c'2Gk �T�� -
Y�
---
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
:i. Plumbing S 1. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Nechanical (Fire
Su ression) $ Total All Fees:
6. "Total Project Cost: $ 3��, �O Check No. Check Amount:_ C'ash Amount:___
x\ ❑ Paid in Full ❑Outstanding Balance Dne:
1EMT bOT Gli.
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructiun'Supervisur License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No.and Street Type Description
U Unrestricted(Build in s u to 35,000 cu. ft.)
R Restricted 1&2 Fari fhvelling
City/Down,State,ZIP M Mason
ry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or 1-ItC Registrant Name
No.and Street
Email address
City/Town,State,ZIP 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
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
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) f
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
-]
y e ering my nam• elow, I hereby att•st tinder the pains and penalties of perjury that all of the information
[it ' e , us, pf.. ion is rue ana -c ate to 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(FIIC) 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 can be found at
www.niass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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 Numberofhalf/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'
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WAS FHNrGTON STRE ET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOU
MAYOR T IObtAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 00Ma[[SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address .J( }_r6W1 A1,16 AYE
Present Mailing Address S6 g.7C WC 4.t/L) qYZ!�7'
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 that 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATUR `
APPROVAL OF BUILDING INSPECTOR
a
CITY OF SALEM MASSACHUSETTS
BUILDING DEPARTMENT
120WASHNGTONSTREET,31iDFLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�tlo-Q r�A/ C,*,CTzc)G--
(name of hauler)
The debris will be disposed of in:
(name of of facility)
(address of facility)
Signature of applicant
p—io -//
Date
;+ Kenewal
EA
r. 'W9@EIA[4W RrIP ACEMENT anAn&rstOC ompim
To whom it may concern:
Enclosed is a permit application package for a project we have been contracted to do in your
town. Thank you in advance for receiving this package by mail. As we work in every town in
the state, it greatly helps us in our process.
We have also enclosed a self addressed and postage paid envelope and would request that
when the permit application has been processed, that you would mail it back to us.
Enclosed for you review in this package is:
o Permit Application
o Home Improvement Contractor License
o Construction Supervisor License
o Proof of Insurance
o Proof of Energy Efficiency Rating
o Signed Contract from Customer
o Permit Fee (if accepted at time of applying)
If you have any questions regarding this application please call me at: 508-351-2200 X55285
Regards
Kelley Donahue
Permit Coordinator
30 Forbes Road
Northborougb,MA,01532
Phone(508)351-2214
Fax(651)-351-4807
Website: www.rencN5 b andersen.wm