141 HIGHLAND AVE - BUILDING INSPECTION (3) cro
The Commonwealth of Massachusetts RECEIVED Board of Building Regulations and Stand E
af�vt RECEIV VIC Y OF
Massachusetts State Building Code, 780 C PECTIONALLEM
Revised Mar 201l
Building Permit Application To Construct, Repair, Renovat RwAh A 11: lb
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appl' d: _ $ - - /e/
t, 3 3
Building Official(Print Name) Signature Date
ECTION 1:SITE INFORMATION
1.1 Property Addres//��: 1.2 Assessors Map& Parcel Numbers Z
/ f"l
rn
I.la Is this an accepted street?yes_ no Map Number Parcel Number c
'O
1.3 Zoning Information: IA Property Dimensions:
Z,oaing District Proposed Use Lot Area(sq fu Frontage(11) tV
1.5 Building Setbacks(It) D m
From Yard Side Yards ear Yard 9P Q
Required Provided Required Provided Required Prod m
1.6 Water Supply: (bLO.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERS"IP'
2.1 Owner'of Record: -
_G/ND/� / O�I/il 6 /9ZJ
Name(Print) City,Slate,ZIP
&!Q ICV _
No.and Street Q 'telephone Email Address
SECTION 3: DESCR(P lON OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(sw Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials Official Use Only
I. Building $ p I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ 0 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ U 2. Other Fees: $
4. Mechanical (FIVAC) $ I) List:
5. Mechanical (Fire
Suppression) $ D Total All Fees: $
Check No. Check Amount: Cash Amount:
C,. Total Project Cost: $ �I�( � ❑ Paid in Full ❑Outstanding Balance Due:
1�1Atlr� �0 1l • O � �l�ll.tT� S�u
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction 6upe,rvisor License(CSL)
License Number Expiration Date
Name of CSL Holder
q r A tl _ r fr I r. List CSL"type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
l Insulation
Telephone Email address D Demolition
51 Registered Home Improvement Contractor(HIC)
T r
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and,Street Email address
• City/Town, State,ZIP Telephone
zSECTION 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 79: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) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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.
Z NJ9 HKYM �-iy
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(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 can be found at
www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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 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"
/COUk q
CITY OF SALEM, MASSACHUSETTS
e, at BUILDING DEPARTMENT
12C WASI-IINGTON STREET,31tO FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
yT�
Date
' lob Location /yZ HqA ar7 ry 1/ ✓� /errs
Home Owner Address � /f hhamA /G�V1r/1 &}-
Present Mailing Address
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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR
']L'1LDLYG IDEPAMLEYT
110 1V.ISHLYGTOW STREET, 3`°FLOOR
TtL (978) 745-9595
K1.NtHERLEY DRISCOLL P•1-X(973) 7•{0-9944
&LAYO"t THOSNS ST.PtEAM
DtRECCOR OF PL;9UC PROPERTY/8t:MDLNG COSLAnSSIONEA
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CMR section l l 1.5
Debris, wid the provisions of lMOL 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 VIGL c
111, S 150A.
I'he debris will be transported by:
ti Z i VQod) f/(Ay lH
(name of hautcr)
The debris will be disposed of in
No,� SijE C fJ,e��
(name of tacdily)
(address o t thm h ly)
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signature of pnmit apptica t
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Proposed Porch
141 Highland Avenue '
Salem,Me 01970
May 1• 20141 Scale 1/4"= V-0"
NEW ENGLAND LAND SURVEY MORTGAGE INSPECTION PLAN
Professional Land Surveyors NAME LINDA HUYNH -p
25 SUTTON AVENUE N
• Oxford, MA 01540 LOCATION 141 HIGHLAND AVENUE
PHONE: (508) 987-0025_ SALEM, MA
FAX: (508) 234-7723
SCALE 1"=40' DATE 4/10/2014 -
REGISTRY SOUTHERN ESSEX
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