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284 HIGHLAND AVE - BUILDING INSPECTION r^� The Commonwealth of Massachusetts RECE�V SERVI ES �s Board of Building Regulations and StiOWiIONAL CITY OF �)4J Massachusetts State Building Code, 780 CMR SALEM 0 %vised Mar 2011 Building Permit Application To Construct, Repair, Reno�D"li/�a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date lied: r2- lding Official(Print Name) Signature Date SECTION I:SITE INFORMATION roperty Adt es( 0 1.2 Assessors iYlap& Parcel Numbers -�L-.i-�S�H L/"D IM I.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: - -- — IA Property Dimensions: Zoning District Proposed Use Lot Area(sq II) Frontage(Il) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(NLG.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal systern ❑ SECTION 2: PROPERTY OWNERSIIIPr 2.1 Owners of Record: �d l. fv(.f O Q Name Print) City,State,ZIP r I No.and Street -- I'elopltoite Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(chec all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. Number of Units Other ❑ Spccil'y: Brief Description otProposed Work: 1- r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only I. Budding $ C) 00 I. Building Permit Fee: $ Indicate how tee is determined: ' 2. Electrical $ ❑Standard City/Town Application Fee ❑'rotal Project Cost(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: d Qo (90 o Check No. __Check Amount_ Cash Amount: 6. Total Pro Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor t,icense(CSL) �f.,, ese 9�3 © License Number ixpirat on Date Name of CSC Holder 1 6 tit �° List CSL'rype(see below) PeM� ' No.and Street Type Description C , _. jJ q i-t IJ Unrestricted(t)uildin s u to 35,000 cu. R. �((1{� —� R Restricted 1&.2 FamilyDwelling CitylTowq State,ZIP M Mason ry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registered H./oine Improvement Contractor(HIC) H C Company Name r HIC Regis ram I-IIC Registration Number Expiration DatNo ant Name Sir -t Email addres,,qr Cit /'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 G to act on my behalf,in all matters relative to work authorized by this building permit appl ation. Print Owner's Nam (Electroni Nign� ve) 4�44) 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(Hlec(ronic Signature) pate 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 Honte 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.nutss.eov/uca Information on the Construction Supervisor License can be found at www.ntass.eov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. 11.) (including garage, finished basemem/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces _ Number of bedrooms Numberofbathrooms _ Number of hall/baths Type of heating systent _ — Number of decks/porches Type of cooling system_ Fnclosed----Open _--- _ 3. "Total Project Square Footage"may be substituted for"Total Project Cost" •w CI-I-Y OF S.1LEM, NLASSACHUSETtS � f BUILDING DEPAR-NW—NT 120 WASHLNGTON STREET, 3iD FLOOR T EL (978) 745-9595 F.LX(978) 740-9846 KIMBERL.EY DRISCOLL �,`A-kYOR Tl IOh41s ST.MERRs DIRECTOR OF FU13LIC PROPERTY/BuiLDr%G COMMISVONER Woricers' Compensation Insurance Af idavit: Builders/Contractors/Electricians/Plum6ere -k t ilicant Informatinn Please Print Le ibl Milne(Rosiness,Drg.miratiom'Individual): /� p / Address: ?o{1(�n City/State/Zip: /i1 ✓h �/T LT446�hone#: V �© Arc you un employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or pan-time).' have hired the sub-contractors ,/ 2.[4 I ant a sole proprietor or partner- listed on the attachad sheet, t 7. 1(Q Remodeling ,hip and have no employees These sub-contractors have 8. ❑ Oentolition working for me in any capacity. workers'comp.insurance. y, ❑ [Building addition (No workers comp. insurance 5. ❑ We are a corporation and its ,,_/ required.) officers have exercised their 10 ff] Iecrrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.�-Plumbing rcpuirs or udditions myself.(No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required) t employees. (No workers' cuntp.insurance required,) 13.❑ Other •Any applicmn Ilut chucks box 01 must also rill out the section bctaw showing their wurken'eumpeaution policy inllrrmarlun. 'I IUTGnWM"%Vhj,uhn,it this Atn(kWlt indicating Ihcy ara doing all work and then hire outside cvnrncton mml nihmil a new afrtdavil indicating such. :(',oumctun Ihul chsck this box most showing the n.une of Ihv nth evmnnun and shalt workers'comp,puticy infunnativn. I unr art eurpluyer tiros&provid/ng workers'cumprnsadun hr.rurunee for my etrrpluyees. Ueluw is the poNcy and Job rile iufiannulinn. �\ Insurance Cuntpany Vane: A _1 Ll � � � i NAJCC Policy q or Self-ins. Liiicc..t it: C� /O/� Expiration Date: f Job Site Address: O0 O � � C 46 N PAVrCity,Sratt:/Zip; ,C G � �9 � o Attach a copy of the workers'compensatloo Policy declaratlon pegs(showing the policy number and expiration date). Failura to secure cuvernge as required under Section 25A\uPitIGL e. 152 an lead to the imposition of criminal penalties of a ling up to S1,500.00 und/ur one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up(o SM.00 a Jay against the violaror. 13e advised that a copy of this statement may be furwar icd to the 013ice of Investigations ul'thc MA for insurance coverage verification. /do hereby cerrify under d pa/ns cord penult/es of perjury that the infuratutlun provide)above is true and CorreerL Si t unre: Date: Phone t � OJlicial we only. Oo nor rvrite in this area,m be completed by city ur rowrr ;fjh hoL City or _._ Ycrmit/l.lttnscN ts,uing Authority (circle one): I. Iioard ofticalth 2. Iluildinq Departnumt .i.Ciiy/fm,o Clerk I. Electrical lo,pectur S. Phtnlbing I lipecror 6. 0(her Contact I'cnnn: Phone a: ^Y V Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor - License: CS-099237 ° MANH T HUYNH` y 26 Spencer Street: x Lynn MA 01905 = W"' Expiration - Commissioner 0 410 512 01 6 _- _ �'.. rt V' /er. rLomrireouraea�ll oyCAIIJJad"r ell AOffice of Consumer Affairs&Business Regulation Q OME IMPROVEMENT CONTRACTOR egistration 150405 Type: xpiration 3128/2016, Individual MANH TRUONCa HUYNH Ef It= r y - MANH HUYNH - 26 SPENCER STREET'- LYNN, MA 01905 Undersecretary a- 1 ` CITY (7E S:u.E.tif, ).YG-1SS,1CHUSETTS ::\:� Ir ��� BCILDL�tG DEP.IRT\IErT �1e fe 120 W.hs"LNGTON STREET, }°FLOOR '1.!L (973) 745-9595 KIStBERf FY DaISCOLL FAX(978) 740-934S NLAyo(L -r,-I0SLA3 ST Piegltl; DLaECTOR OF PGBUC PR0PER7y/3L•jLr)LqG CONOIISSIONEx Construction Debris Disposal Aff1davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 QJR section 111.5 Dcbris, ;uid the provisions of IbtGL c 40, S 54; Building Permit d is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disp 111, S 150A. osal facility as dafincd by ,vICL c The debris will be transported by: y �Z b) 5R7 55! (nJmc ut hauier) The debris will be disposed of in (name of farllity) ------_(adJress of filcility) 5iplarurC p(J)CI'Rfl(dI](7hidlif -- n I ' I 46'-7" PIPING-{ uuu � i O CHIMNEY COLUMN N P O CLEAR CEILING 00 z HEIGHT = 85" AREA = 1 ,025t SF ° m m 5 -7 35'-7" r EXISTING _ 284 HIGHLAND AVE 12' 22'-7" 10'-8" 8' O :. EGE BEDROOM I rn El CHIMNEY P o_ (O REJ 00 Z � D m Z U) r* m CABINET SINK CABNET FRIDGE m 4 . . a 5 -7" 2' 284 HIGHLAND AVE q79 - �35-- 07 a