141 HIGHLAND AVE - BUILDING INSPECTION 3 The Commonwealth of Massachusetts CITY OF
Boa rd of Building Regulations and Standards SALEM
UI Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Reno ate em sh a
One-or Two-Family D,velling
This SectloD,FOr'OE{lClal U
Building Per mit Number:
': DateAp hed '.
Building Official(Print Name) `Signature Dat .-
SECTION 1: SITE INFORMATION
1.1 Property Address- 1.2 Assessors Map & Parcel Numbers
/�idGr74�wj,✓ P r 50
1.l 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Zone: _ Outside Flood Zone?
Public❑ Private ❑ Municipal if yes❑ unicipal❑ On site disposal system ❑
SECTION 2-' PROPERTY OWNERSHIP"
2.1 wnert fRe)ekco
Name(Prriinntt) /����,,/ /�, City,State,ZIP�/��'
/ ll�II G�G6lGf A71�Q• Zj17-02,-4Z`� y Y1�ro'ny �xE(t�{�llVl{{i/r1L>`
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK" all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': r
ox aDyi,
SECTION 4: ESTIMATED CONSTRUCTION JCOSTS-
Estimated Costs:
Item Official Use Only_
Mater Labor and ials
f. Building S (( 1 Building Permit Fee S ' Indicate how fee is determined:
2. Electrical S ❑ Standuci City/Town Application Fee
❑'Total Project Cost',(Item.6)x multiplier x
7PILImbin,aS Other Fees: SL(FIVAC) $ Ltst o" lxt�(Fire $ 'totalAll Fees: S
ZOa CheckNo. CheckAmount: i Cash Amount:
. ect Cost: S' 12 Paid in Full ❑ Outstanding Balance Due:
J
SECTION 5: CONSTRUCTION SERVICES
5.I Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Ilulder
List CSL Type(see below)
No. and Street 'Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
_ R Restricted l&2 Family Dwelling
City/Town, State, ZIP VI Masonry
RC Rooting Coverin,
WS Window and Siding
SF S01id Fuel Burning Appliances
I Insulation
'rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Registration Number Expiration Date
IIIC Company Name or IIIC 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
1, as Owner of the subject property, hereby authorize
to act on my behalf,.in all [natters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[ 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.
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. 1.12A. Other important information on the IIIC Program can be found at
%ww.masioov:%uca Information on the Construction Supervisor License can be found at www.ntass.eto�:�dpti
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 ;trea (sq. ft.) _ Habitable room Count
Number of fireplaccs_- Number of bedrooms
Number of bathroouts _ _ Number of half/baths _
Type of heating system --_-- Number of Necks/porches _---- --
1'}'peof cooling system.---------- — EuCIOSCd_ ------- Opcn _
3. "total Project5yunre Footage" nmy besub_tituted t01 Ibetl ProjoctCust -_-_, ---_____--
CITY OF SM-0ol
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNS6 SUMMON
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RomeOwnerAddress C .
Home Owner Tel vv�
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Prrsml Mailing Addaeso
The current exemption of"Homeowners"wan extended to include ownar-0ccupied
dwellings of two Units or tear and to allow such homeowners to engage an individual for
hire wbo don not poarars a licenser provided that the owner act@ W supervisor'
DEFvM0N OF HOMEOWNER
Person(s) who awns a pared of land on which hdshe resides or intends to resider on
which these is, or is intended to bo,a one or two thmily dwelling,attached or detached
structtua 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
eownalshall submit to the Building OQ t�.on a form acceptable to the Building
Official, that hdsho be responsible for all such work performed under the Building
Permit
The undersigned "homeowners'assume@ responsibility for compliance with the State
Building Code and other applicable by-laws and roguladons.
The undemigned "homeowner'certifies that he/she understands the City of Salcm
Building Department minimurn impaction procedures and requirements and that hdshe
wiil comply with said procedures and requirements.
HOMEOWNERS SIGNATLRE/4ec� f
.kPPROVAL OF MLDING MPECTOR
See other side for state code
kp;
C.
t
r CITY OF SiUZNM �SSACHUSETTS
120 %VASHLYGTON STREET, 3' FLOOR
TEL (978) 745-9595
1<1�t3ERLEY DRISCOLL F.LX(978) 740-9846
A.L�YOR THo+w ST.PiERRz
DI.'tECTOR of PUBLIC PROPERTY/SUMI)ING COS3IISSIONER
Construction Debris DIsposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of tile State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit /a 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 lvSGL c
111, S 150A.
The debris will be transported by:
�Ilti� �4 zL
(name of hauler)
The debris will be disposed of in
_ (name of
_
f faality)
(J'Idle s of faculty)
signature of permit applicant
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