121 HIGHLAND AVE - BUILDING INSPECTION The Commonwealth of MessachuWtgpECTIpN bL SEft CITY OF
�
Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 JA1�MAY 13 /�, �ebq
ised blur 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only ,
Building Permit Number: Date Applicdt
Building Oiicial(Print Name). Signature. Dat
SECTION 1:SITE INFORMATION'
�(1 1.1 Property Address: 1.1 Assessors Map&Parcel Numbers
1 I.I In Is this an accepted street?yes J no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yams 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:
Zone: _ Outside Flood Zone? Municipal PfOn site disposal system
PublicPrivate❑ ❑
Check if es❑ p
SECTIONZ: PROPERTY OWNERSHIP)`
2.1 Ownerr of Record:
�1 W� (i?To1J�oS . SIU'ry�- A
N�me(Print) City,State,ZIP
1,)21 f1�11laad A,� Cn%-%p4 . 9S-73
No.and Stre -- Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constnrction❑ Existing Building Ef Owner-Occupied ❑ 1 Repairs(s) d I Alteration(s) ❑ 1 Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed\York': 5�r
SECTION 41: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building ; I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CitylTown Application Fee
?. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ POther Fees: S
4. Mechanical (FIVAC) I S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6. 'rotul Project Cost: S j g'vO ❑Paid in Full ❑Outstanding Balance Due:
m�I�� -ru STONwv� S� r g
'Mrue � awe
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) P cgs") �_11_ it
�.o�c�. an License Number Expiration Date
Name of CSL Hold
List CSL'fype(see below) f/
to e'ljp��"'"L C�r qd ry a Description .
No.and Street
U Unrestricted(Buildings no to 35,000 cu. It.)
�l MA D Restricted I&2 Family Dwelling
Cit lfown,State,ZIP Ni IMasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
59 I Insulation
Tcle honeone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC) 178qq6- to S- lry
�4c/4.✓T �P dd S7j • _ HIC Registration Number Expiration Date
HIC Contp;I�ny Nmne or HIC Registrant N;une
,^,SAS VGrf6 JA 5-7—
No. and Street Email address
L✓✓✓ MRState O/qDt/ 78/- -h71(
C' /Town, ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:e. 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 ..........13' No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO RE COMPLETED WHEN
OWNER'S AGENTOR CONTRACTORAPPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize MV& Ammdmri A• t1 bus i
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
1 ate/ S10 eu-s
Print Owner's Natrte(Electronic Signature) Date -
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
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 art owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will tort have access to the arbitration
program or guaranty fund under b1.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass.."ov:!0ca Information on the Construction Supervisor License can be found at www.mass.e0v:!Jns .
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) '!1 _.(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 ofcoolingsystem Enclosed Open_
3. •Total Project Square Footage"may be substituted I'or"Tut:d Project Cost"
Y° CITY OF S:1LENf, NiskSSACHUSE-FrS
i
BUILDING DEPARTME.\T
120 WASHINIGTON STREET, 3'n FLOOR
TEL (978) 745-9595
F., x(978) 7a9846
ICI.N tBF a r F-Y DR]SCC L
7
w;VL�YOR }loitfAS ST.PIF1tR8
DIRECTOR OF PUBLIC PROPERTY/BUMDIVG CONNISSIONER
Workers' Compensation Insurance AIITdavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Picace Print Leelbty
NillnelBusinrssOrganiratinn•Individual): .Gt ,/ifs.,+_- . /QAc/ .C1C L'i5
Address: �V/S ✓EILnlA -Ir'
City/State/Zip: Zi n/n/ MA 0)90� Phone d: "7&1
Arc you an employer"Check the appropriate box: Fype of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.Ellam a sole proprietor or partner- listed on the attached sheet. t �• Remodeling
,hip and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity,
workers'comp.insurance. 9. ❑Building addition INo workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repair or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or udditions
myself.(No workers'comp. c. 152, q 1(4),and we have no 12.0 Roorrepairs
insurance required.) t employees. [No workers' 13.0 Other
Pomp. insurance required.)
.Any applirum our chocks box el muo also rill out he urban below showing their workm'mmpwnsaden polity uun maoon.
'I Inmouwncn wha+ubmit this affidavit indicating thry ate doing all work and than hire outside contmcte s must submit a new airldavit indicting such.
:rlmdrwuun that chtvk this box muss anwhod an addniunal,howl shuwing thtl name of Iha sub amrsdan and their worken'tomp.policy infommion.
1 ant all eurpluyer that it providing fverkerr'cunspenratlan inruruncefor my eutp/uyees. Below 1s du pollcy and job site -
iufunuulion.
Insurance Company Name: I iJA. --.---
Policy 4 or Srlf-ins. Lic.N: .>1'�c�so29'�O� Expiration Date:
Job Site Address; /cP/ /-/,AIAJ A47- City/State/zip: SAle-n~- rAA .
Attach a copy of the workers compcnsatlon Polley declarailen page(showing the policy number and explratl(1n data).
Failure to secure coverage as required under Suclion 23A of,LIGL c. 152 can lead to the imposition ofcriminal penalties of a
fine up to S1,500.00 und/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may I% furwardcd to the Oflice of
Invrsfigatiunx al'Ihe DLL farinsurance coverage verilicaliun.
/du hereby certify cinder the puhrA.411d pendli r. of per'ury rlml the it junrturlon provided ubuve it true and cornet
Si•.,n lllre; �N w / lY1'� Date:
Phonc d:
OJ/iciu!use wily. Du not uvrire in this area,tobe cuurplelyad by city of rurvn nfJleiuL
City nr Town: _ __ .__ Permit/1.1cense N__.
"
Iss guin Authurily (circle unc):
I. Board of licalth 2. Building Beparhnral .I.Citylfnwit Clerk 4. Electrical lmpector 5. Phrubing Inspector
b. Other
Contact 1'erson:__ ---.. ...___. __ Phone a: _ i
r
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHNGTON STREET,3'mFLOOR
Ti L(978)745-9595
KIMBERLEYDRISCOU FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBIJCPROPERTY/BUILDING ODbIIvIISSIONER
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 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:
(name of hauler)
The debris will be disposed of in:
cl
(name of facility)
�'aM.,,c,ce,a1 � ,C✓ i i rvyp„
(address of facility)
Signature of applicant
Date
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