122 HIGHLAND AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Ip/ Board of Building Regulations and Standards CITY
Massachusetts State BuildingCode, 780 CMR, 7"edition OF SALF.M
/1 /I j;� Revised Junutir v
Building Permit Application To Construct, Repair, Reno ate Or Demolish a 1. loox
r I One-or Tw - umily Dwelling
This S41ionlFor Official UsidOnly
Building Permit Num r: a App ed:
Signature: y/ e
Building mmissioner/In for of Buildin Date r�
SECTION 1 SITE INFORMATION
I.12 2perty, Q Nit 14Y/ V 1.2 Assessors Map& Parcel Numbers
I.//1 a 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 11) Frontage Ill)
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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Checkif es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.I r'of Record:
Name(Print) A/dE for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKS(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'': M,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
r4.
Building S I. Building Permit Fee:S Indicate how fee is determined:
Electrical S ❑Standard Citylibwn Application Fee
❑Total Project Cost(Item 6)x multiplier x
Plumbing S 2. Other Fees: S
Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
6.Total Project Cost: S
�O Check No._Check Amount: Cash Amount:_
LU 0 Paid in Full ❑Outstanding Balance Due:
r '
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 2�
JJAW) License Number lia ireliun )ate
v N ol''S1--11 (�1 nV I.ist CSL Type(see below)
r pe Dewri lion
U llnreslricteJ u to 35,O00 Cu.Ft.
R Restricted I&2 Famil Dwelling
Signature M masonry Only
RC Residential Roofind Covering
rclephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning ADDlianCC Installation
D I Residential Demolition
5.2 Reg stered Home Improvement Contractor(HIC) / qo
111c Comp y Name^or1 HI 'Registrant ry,yne Registmtiun u ber
n
Add
Signulu U C/t elephune
SECTI 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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...........C3
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 Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Of
I �N) ,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 m
. tgnature of Owner or 1 orize Agent Da /v
Si ed under the aiand nalties of 'u
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 no 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 IO.R6 and 110.115,respectively.
2. 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"may be substituted for"Total Project Cost"
�A CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
111G M111 "Illy,'•II
I.0\t AIt Il\O wIV SMIJ #S•\t l\t, \Lhi.\I I II J I,•.1'1 _
1'rI:9711.745-9595 1 \!c:978-7QY1446
Construction Debris Disposal Affidavit
(required lur all demolition:utd renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
Hama of Imuler)
The debris will be disposed of in
(name 7-raolny
a.e..,Irr,.�rlyl
z2 kQA
.Ignature emit applicant
T ��D
date
kln•dl :r
CITY OF SM-E.N[9 iNLALSSACHUSEM
BL iLDti 1G DEPuntENT
120 Wmmmic;TON STU". )'a FLOOR
TEL (978) 743.9595
F.ut(978) 7449&W
KINCBEA"Y DRISCOLL
HAYOIt T?WstAg ST.Pf=RRs
DIttWMROPP{LuPROPERTY/nILDNGCO-%c%assloaER
1Vurkers' Coinpeassiloa Insurance AIIldaviC Ouilderi/ContractorwElectrlclantiFlumben
annllcant Infarmatloll Plean Print Les iblY
V21ne IeunnesrOrgaolirsnenlnSr dua11:_ 1�/,1y'N //V/ ✓W� 1
Address- 706 City/StatdZip _1 1N� f� phone* A- /
vr.you me eatpbyer?C Y the AppMP�re belts Type orpmjocl(roqulred}
I am a unpbya will 4• ❑ I err a{•send eoakattae and 1 K ❑Now construction
cmployces(IWI and/or puut-time).* have hired the sub-comrades
2.❑ I err a sob pmprictw iY Pwuwr- listed On 11e atraelted rheca t 7. OR ailing
.hip and haw no empbyces Then sob•eamro man have s. ❑Demolition
working ror me in any capacity. wortas'cotp6 inwamg
9. Q ttaiWGy addition
I No waked comp insurance S. ❑ We are a conpertioe and is
offmn haw eaaeiaad their I O.Q Electrical repair a additions
nMtn a homeowner
ri of MOL 11. Plumbb or addttione
).❑ 1 am a htltrrcawtax doing all work Yha °��Per ❑ {repairs
myself.(No worker'comp C. I 32,f 1(4),and wo haw no I U mf repairs
insurance required.) ► cinpbyeat.LNG wartme `raja
camp inmmm mvked.J J. I S. Othar
'Any uPtaraal iti•saws sera e1 nwo alit to w iM teens hM 1 14 fads wrew'cormpwoo600 Pocky idwwrba.
'16wam me who suborn Nor aradek iedlndry dry aw daiiq 80 work sad 60 NO VA"reeaeraca won sub ash a new aft"inil@aiq awry
t'.wiw,oan dun rkrek elle oa~4114361101111130 3M*AfMl AM Hawke dw err stft a►tawrwwit ad drM works'=Is*pdkr itdwwWa
/am aw ewpAlydl rAat d yravGflwR 1rwAlra'ctrwplraredrn ltrsnrntsee/iI aq rarpGryaea ddfaw AI the pNfey ut/`sb s/ar
inforruanitlla
In.urrnce Company Nameh l/
Policy a or Self-ins. Lit.p N/C�¢�I � 2d Expiration Darr. n�
1uk Sire Address:1� AJ Ari d ,L'e—e CityiSlae/Zip:�/
Attack a copy of the worker'compoleubn policy daeteratiose pap(skndng cha policy number and aspiration dart)6
Failure to shun coverage as required under.8caloo 2JA of MGL a. 152 can lad to the imposition of criminal penalties oft
fine up to S 1.500.00 and/or and-year imprisonment,err well as civil penalties in the form of a STOP WORK ORDER and a floe
Of up to S2J0.Doi day Jusinsl the violator. Ib advisod chats copy of this slatemum maybe rurwarded to the 0111ce of
Invcanyatiuns of ilia 171A for insurance covcraso writleatwa,
/,/a hereby cerrijy wn1 to ins and pendlder el per/usy that rob in/arwadon provided a w i true ref•'cared
ILLYI)
,z /�
OQfctd WI mifyi, Da not Write in tbs a/eq to dI.alnOfird by miry a rerun n//feia{
City or ruwn: PermiWIcense e
Muing Aulhanty(circle line):
I. Iluard ul Ilrallb 1. Rudding neparment ).citytrowa Clerk !. [lectriul inspector S. Plumbing Impeeror
6.111ha _
0
lmtacl Peron: _ . _ Phoned•
Massachusetts - Department of Public Sal'et%
Board of,Buildiiw Regulations and Standards -
�J Construction Supervisor Specialty License .
License: CS St. 99557
Restricted to: RF,WS
i
GLEN JANVRIN
306 ESSEX STREET
SWAMPSCOTT, MA 01907
Expiration: 4/22r2012
(innmissinner Tdh 99557
-. -.�/���oxwrnaeu/�eall�C o�✓l>'.aoaac�utael�d -
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration.--159038 Td/ 294512
Expiration 312612012
Type:,) p �11
G.JANVRIN HOMEMPROUEMENT
GLEN JANVRIN'�"
306 ESSEX ST
SWAMPSCOTT,MA bt 00T Undersecretary
d