15 HIGHLAND ST - BUILDING INSPECTION (2) I� The Cweallh of Massachusetts
�/ SJ ommon assacus
Board of Building Regulations and Standards Town of
.Massachus
etts State Building Code, 780 CMR, 7'"edition
w� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kwmodwo
One- or Tiro-Fmstlls•Duelling ANN&
This S tion For Official Use Only
Building Permit Nu ber: Date Applied:
Signature:
Bwl Commissioner to of Buildings Date
SECTION 1:SITE INFORMATION
1.1 )Pr e y A ddIess: �-,J_ 1.2 Assessors Map& Parcel Numbers
1.la Is this an cepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: v 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage 00
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.a0,ls4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNE HIP'
eA-
a in1 Address for S e:
Si t re Telephone
SECTION l: DESCRIPT N OF PROPOSED WORK'(check all that apply)
New Construction O 1 Existing Building❑ 1 Owner-Occupied Y,I Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ 1 Accessory Bldg. O 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OHielal Use Only
Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
J Plumbing f 2. Other Fees: f
4. .Mechanical (HVAC) S
5 .Mechanical (Fire S
Su ression Total All Fees. f
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
'' 7 Liceroe Number Expiration Date
N.yoe of CSL Hplder Ltst CSL Type bce below)
a
i Description
Address
U Unrestricted(up to 35,000 Cu. Fr)
R Restricted Ik2 Family Dwclhn
Signature M Masonry Only
RC Rcsidcntial Ron Covering
Telephone VS
Restdenual ofi
Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Addreu
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 2SC(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. j
Signed Affidavit Attached? Yes .......... O No........... G
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGIE14T O CONTRACT R APPLIES FOR BUILDING PERMIT
1 —. as Owner of the subject property hereby
awhorize to act on my behalf,in all matters
relative to work aut o 'zed by this building permit applicati n.
Signature of Owner Date Ali
SECTION 76:OWNERt OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES: it
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor j
(not registered in the Home Improvement Contractor(HIC)Program), will W have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R3, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfbaths
Tvpc of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be .uhstituted for 'Total Pro)cci Cost"
CITY OF S.UYDv1
PUBLIC PROPERTY
DEPARTMENT
Vwrw i]ourAmuer.TCNSTUM*&MAK MAMACM310TS01970
TIM 9-s•tassss•F.uc 979.7+&9&M
HOMEOWNER LICENSE EXE.MMON
Please "I
Date
Job Locados
Home Owner Address
Home Owner Telephone - o
presw M=Hng Address — s-
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 HObMWNMt
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 accessoryto such use and/or.farm structures. A n who constructs more
P�
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 proced es and requirements.
HOMEOWNERS SIGNATUIM W0.,�I
APPROVAL OF BUILDNG INSPECTOR I
See other side for state code
s CITY OF SALLM
PUBLIC PROPRERTY
>,,.,. . DEPARTMENT
Construction Debris Disposal Atlidasit
OvLlmrcd air all demolition :ufd renovation work)
In accordance w ith the sixth edition of the State Building Code, 7S0 CTIR section I 115
Dcbris, and the provisions of AIGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting front
INS work shall he disposed of in a properly licensed waste disposal Ilacility as defined by MGL c
111. S 150A.
The dchr's will be transported by:
Lc
I Fla nJc of Ilai kr)
I he debris will be disposed ot'in
01.Jlne of faalny)
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