399 HIGHLAND AVE - BUILDING INSPECTION The Conunomkcalth of Massachusetts ---
t Board of Building RCgulutionS and StandardS I ( tlt
° \IINII'll'.\I I I 1
Mass:rchusctlS State Buildine Code. 7511('h1R. 7ib eJiliu" I NI
Building Permit Application TO ('onSlruct. Repair. RenoSate 01 Denwlish ❑ Kr.n ,1 Loma
(btr a Tt o- •aurtilvOilelling
' his S -ie For Official Use Only -----__�
Building Permit Number' Date Applied: s Z• ` 0 -1I
t Signature
` V O
Budd Dane( _— -------
SECTION I: SITE. INFORMATION _ l
.1 Prv�9 [716ji �V C L? Assessors .Map & Parcel Numbers ------- -
.P.I'I
I.la Is This :m accepted street:' Yes_ no btap Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy to Fronwge iit)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Reyuin•d Provided Rcyuued Provided Raymred Pruu ded
I
1.6 Water Supply: (M.QL c 10, §51) 1.7 Flood Zone Information: ' 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:'
Public ❑ Private❑ Check ifyes❑ Municipal ❑ On site dislwcal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Record: , /C�faQl�l yg99 44b b�d Ayy iQ._
Name(Prino .L�lT 4 Address for S rvice:
�MCA a /-97k- 7yl-%/&& -
Srenature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check 0 that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s) V1Alteration(s) ❑ Addilimm ❑
Demolition apfAccessoty Bldg. ❑ Number of Units Other ❑ Specify:
rief Description of Proposed Work �_� y
—(
- ' — ---
r
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
hem I Labor and M:uerialsl Official Use Only
I. Building $ L Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Tuwn Application Fee
?, Electrical $ ❑ Total Project Cost (Item G) x multiplier x _
3. Plumbing $ ?. Other Fees: 5
J. Mechanical IHVAC) $ List:
5. Mechanical (Fire
Su� ressium
Total All Fees: $
_ Check No. Check Amount: __ (•.toh .\nn Rurt
t, Fotal Project Cost: S /ADD I 0 Paid in Full 0 OuhtanJing Balance Due
r
SECTION 5: CONSTRUCTION SERVICES
� r•
5.1 Licensed Construction Supervisor (C'SI.1 ,••,I
1_ncn,e Number — —_ I`.spt ruum D.uei• ,�
Namc id l'SI.- Ilnlder ---
Lul C'SI. l\ju nrr below I _ I
.I�fie - Ur,cii noon —1
\JJres, — J
l 1�nrnlnclrJ loop ur �i.IN1U Cu ht
—_—_—_ __----- — K
i Signauae Vt i ARIr:uonnernnrt JwUl n&Kho
dinnc Cl „Dercllm<
c ut`RC R ,iJ �-_
Iclephuue \\S Rc'I'L nl i.J \\i nJu.. ..lid Si.hii—_
SF Jcnual Soli) Ilwmrte \l,,I i.n ii_Li•t_dldtm a. I
D RcaJeuu,;l Druedunm —__�
5.2 Registered home Improvement Contractor IIII0
Ii IC Company Name or IIIC Reguuaut Name Regt,tratwn .Numher i
\Jdrese
G rpiraUon Dal..•
I _
5ignmure __— !elephonc
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)1
Workers Compensation Insurance affidavit must be completed and subrui tied with rho application. F allure his pnntJc
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
I _ as Owner of the subject property hereby
authorize __._ to act ('11 in,/ bchalt. in all matters
;alauce to work authorized by this building Per application. -
I i
Signature of Owner Dule _
SECTION 7b: OW'NERt OR AUTHORIZED AGENT DECLARATION
— I
I , as Owner or Authorized Agent hereby declare
that the starements and information on the foregoing application are true and accurate, to the best of my knowledge and
---
nnl Name
Signature of Owner or Authorized Agent — —_—LL Date
(Signed under the pains and penalties of per u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered conterctor
(nut registered in the Home Improvement Contractor(HIC) Pro g ram), will not have access to the arhitrauon
program or guaranty fund under M.G.L. c. I12A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be hound to 7,40 CNIR Regulations 110.R6 and 110R5, re,perncely�
' When ,ubstantial work is planned, provide the information below:
Total flours area 1Sq. Ft.) iincluding garage, finished basmnentJatres, decks or ponhi
C'rn ins In,rrrg area rSq. Ft J Hahitable room count
Number ct toeplaces Number tit hedrooms
Numher of hathnn,nts Number of h,1lNhalh,
hype of heating sy,tem _ Numher tit deck,/ por.hc,
I spe of :oohng ,\',rem ,ed
1. 'Total Project Square Footage- tnay be substituted for Total Project
CITY OF Sm Em
PUBLIC PROPERTY
DEPARTMENT
VAroa 130 wANUMMON SrMEsr•SAL934 VAUAOU.'WM 01970
TM-97.a•74SM"*FAX 978-740-9646
HOMEOWNER LICENSE EXEMPTION
Plesw Prllst
Date �ll7�Pl6 �
Job Location 19/�l q`I�CG>r!(l lll�al L l P Ya 11, � 7�
Horne Owner� �—
Horne Owner Telephone 1�
Present Mailing Address iQ /�c�szn�4 A 4 m ,
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 who.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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
• ': CITY OF SALEM
A.�r
PUBLIC PROPRERTY
DEPARTMENT
••,I ,,,; I', \\T,I 11%i SIN SI'.,1.1'r • 1.\1 I M. %I
I� � ','8.•i;.'1;'g � P fix: 'i'S.•J:"\�M1
Construction Debris Disposal ,affidavit
(ret{uired liir all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 Cb1R suction 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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 MGL c
111, S 150A.
The debris will be transported by:
�o S ��.��ro�cy
(name of hauler)
The debris will be disposed of in
(name of latillm
5A%r? , ILI
(odtlrrs ur Ix'il tyl
,ignat rc of prnnrt applicant
vvv !v/ late