386 HIGHLAND AVE - BUILDING INSPECTION Tb-1 y —I 3 zo
The Commonwealth of Massachusetts
°a Board of Building Regulations and Standards.. RECEIVED CITY OF
Massachusetts State Building Code, 780 CiEIR'PECTIONAL SE RVICEALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovat�Dol ll aA I: 20
One-or Two-Fancily Dwelling 1'' IIUUuu l
This Section For Official Use Only
Building Permit Number: Date Applied: 4 // t
1
Building Official(Print Name) Signature to
SECTION 1:SITE INFORMATION
1.1 Property Address
3 S6 :N 1.2 Assessors Map At Parcel Numbers
�rrr�L�„Q �ve
I.In 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
n, 2.1 Owner}of Record:
Name/(Print) City,state,ZIP
r?(P 41 a h Ict.nd A v-e . 91F� 3(Q l k�3 red�ecalo ycthou
No.and Street Telephone Email Address -
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building 91Owner-Occupied Repairs(s) ®- Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
3 �eP/w���P.wI wr ows
SECTION 4:ESTIMATED CONSTRICTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Buildine $ f t�i ( 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CityNown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ —�
4.Mechanical (HVAC) S List: Ce�
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S /S'00 ❑paid in Full ❑Outstanding Balance Due:
N�P lt— Sty t 1. p . 8 t g
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
o ss`,� a 16/ �� r
S ,vim D j r-4, Xntq License Number Expiration Date
Name of CSL Holder
List CSL Type(sec below)
PO gov 3 S6
No.and Street Type Description
D 3 (; 5-/9 U Unrestricted(Buildings up to 35,000 cit.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
W 3 U- 3 3 3o2 I Insulat on
Telephone Email address D Demolition
5.2 jRegistered Home Improvement Contractor(HIC) rrl 6 FS
S'v`r'e D t L 4,�414 G' 4C, HIC Registration Number Expiration Date
HIC Company Nat or HIC Registrant Name
Po en S .3 SG C
No.and Street I ,3 6 S-3 3 3l Email address
Ci !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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
rV 1,as Owner of the subject property,hereby authorize S4-eye —.�)) Chi)f a Vrz
IF to act on my behalf.in al matters 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 acqftrale to th best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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.mass.¢ov/oca information on the Construction Supervisor License can be found at 3mDKmass.eov/dpss
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"maybe substituted for"Total Project Cost"
T
CITY OF SiU-EN1, lAL1SSACHUSETTS
4 BUILDING DEPART\IE.\T
1 psTF �
120 WASHIINGTON STREET, 3w FLOOR
TFL (978) 745-9595
F.Aa(978) 740-98.16
Kl\IBERLEY DRISCOLL
,sAAYOR THows ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCRDrNG CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Guilders/Contractors/Electricians/Plurnbers
Applicant Information Please Print Legibly
1 l
N:IInC (nosiness Organisation.'Individual l: _ /�� v1J I C�c vj-V jQ G,
Address: PC) 13 e)>< 3 5 l
City/State/Zip:71/P.t../ ht✓ IV)ll`. 0 3 t s 9 Phone d: ��I 3 g `/' 3 3 -3
Are you un employer!Check the appropriate box: 'Type of project(required):
I.01 I am a employer with 4. ❑ I am a general contractor and
employees(full and/or part-time).
• have hire)the sub contractors 6. ❑Now construction
2.❑ lama sole proprietor or partner. listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. (] Demolition _
working for me in any capacity. workers'comp.insurance. 9, ❑ DuilJing addition
(No worken•'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required) f employees. (No workers' 13.❑ Other
cutup. insurance required.)
•Anv upplinnt Ilul chucks bux 01 must also fil I uut the sec two bcluw showing their wosken'eumpinsatlun Policy IIIlilmlallan.
'I lomcm'Iwn who whmil this alfidnvis indicating they arc doing all work and then hire outside caatnctan must submit a new ai rdavit indicating suck
:C-,mr:wtun Ihot Ovals this box must uuachcnf an addiliuwl:hut showing Ilia n.unc of the subecntnctorx and[halt workers'comp.policy infurmatien,
/one can emptuyer that 1s providing Ivorkers'coritpeusadwt insurance for my employees. talon,is Ilia policy widfub rule
hrfornration.
InsurunceCompanyName: DNC- t�+
Policy it or Self-ins. LLiic. d: !A1 - r'S �J —/ /�i' -O 1/ Expiration Date: ? ` /,
Job Sife AJdruss: J 9-b f�.G/��1�.-,.l �V'� City/State/Zip;
Attach a copy ul the workers'compensation policy declaration page(showing the policy number and explr2doa date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as Wall as civil penalties in the form of a STOP WORK ORDER and aline
Of up caw 5250.00 a Jay against the violator. Ile advised that a copy of this statement may be furnvardcd to the Office of
In vcsligaliuns oflhe OIA for insurance coverage verilicafion.
/du hereby c•enify �ro,(yd{/yJ�•e tyrep�/tfp i s�air d-perm allies of perjury that the hifurrnutlou pro videe d a ovres,true and correct
Dam'
Phtlne,,: Jk/- 3929- 3J 3a�
Qf ficial use only. D a nor Ivrite he this area, to be cumpleted by city ur a1
City or'Fuwn: _ .__ Permit/I.lcemse p
Issuing Authurity (circle one): 71111. �11111,
I. Boardof Il
eahh 2. fluildlnq Departutent 1.citylfonuCierk J. Electrical luspcctur 5. P
6. Other
Coolact Vertnn: 1 hone a:
I
a
QTY OF SALEM, MASSAGIUSETTS
BUILDING DEPARTMENT
120WASHNGTONSTREET,31DFLOOR
TEL.(978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAs STTIERRE
DIREcroR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
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 issued 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:
wmsk-
(name of facility)
12 �' / pe*':�Vjj
(address of facility)
Signature of applicant
Date
Office of Consumer Affairs and Bia mess Regulation
u0 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Cb tr etor Registration
Registration: 116688
r-� Type: Individual
Expiration: 7/6/2016 Trq 252862
STEVEN PAUL DICHIARA j !
STEVEN DICHIARAMR,
68 .,
68 WHITTIER ST
NEWTON, NH 03858
�c
a `Update Address and return card.Mark reason for change.
Address Renewal ❑ Employment Lost Card
SCA1 Co 20M-05/11 --------"- ' --
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor I&2 Family
License: CSFA-055622
STEVENP.DICEIAUkA
� '- �:
68 Whittier St F
Newton NH 03855
r,1
J..L..�� J1 'a Expiration
Commissioner, 06/11/2016