41 HIGHLAND ST - BUILDING INSPECTION (�! The Commonwealth of Massachusetts Town of
l\ 7 Board of Building Regulations and Standards
alt Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
ilildq-
Building Permit Application-To Construct, Repair, Renovate Or Demolish a
AWOL
ne- or Two-Fa
mily Dwelling
This ection or Official Use C
Building Permit Nu m Date Applied: 3 2
Signature:
Buil mg Commissi r/Inspect r of dings Date
SECTION 1: SITE INFORMATION
1.1 roperty Address: 1.2 Assessors _Map& Parcel Numbers
/� ��tid? �Z\
Ma Number Parcel Number
1.1 a Is this an accepted street'?yes_ no p
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: 4( —5 C
c'Li.ct- R at 1 TR ST
Name(Print) Address for Service: 4 ,r
Signature Telephone
SECTION 3: DFkCRIPTION OF PROPOSED WORK'(check all that apply)
New Constructio Existing Building Owner-Occupied ❑ Repairs(,) Alterations) ❑ 1 Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Pro..�°sed Work': klt >ts1" -5o `1tRLAPu& Z.PPCCKc ll
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcial Use Only
Item Labor and Materials
I. Building S 2c3- 00 O. W 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
-- 3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
Csi
5. Mechanical (Fire S Total All Fees: S
Suppression)
• Check No. C cc t Amount: Cash Amount:
6. Total Project Cost: S aid in Full ❑Outstanding Balance Due:
safTt( h7idnr c7M r wA� o J g s 2
/EiTnl. �
vlztse.(�
SECTION 5: CONSTRUCTION SERVICES
�JLQ(l>
icensed Construction Supervisor(CSL)
CS �('3'12 (a(l'G a
r7, —�( .viJ" License Number Expiration Date
N.4me of CSL-Hglder List CSL Type(see below) V
Address T Descri Lion
U Unrestricted u to 35,000 Cu. Ft.)
V(ep{S R Restricted 1&2 FamilyDwelling
ture � M M1tason Only
RC Residential Roofing Covering
Telephone —'1 WS Residential Window and Siding
Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) � -.1G (`j
NP-t0 T'RR.l t�
HIC Company Name or HIC Registrant Name Registration Number
S7 ST u-,Pf:y3u r yA o(kK4 lo►zz f o9 Pat:
Expiration Date
e Telephone
e T
ECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be comp eel and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the but permit.
Signed Affidavit Attached? Yes .......... O No...........No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, w it-bo- I `11--(6 �, as Owner of the subject property hereby
authorize 7--wo<L4.- to act on my behalf,in all matters
relative t iork authoriz by this building permit application. J/(/�1q
Si hat'urc of Owner ��\�--- Date �` �3` `
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
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:
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, 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 halUbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
~: CITY OF SALEM
V ,9) PUBLIC PROPRERTY
DEPARTMENT
,1111'. x I \' ,Mhl,'I I
vl o,at i1L Wn,nl jai L,.irl Ll:r • Snu%4. IV/.ix\.%' ill it l is J197^
1 '178-71545't5 • hix 9714J4C 1,4Ni
liYorkers' Cumpensation Insurance li fidavit: Builders/Contractors/Electricians/Plumbers
)lieant Information � Please PPjriinttsL�e�eihl
� )w1� y
Name IBu,uicvsa�r;;anv,uioiVlndi,rituall: `mo 7l` ' La'
,Vld(rss:
O , 130V r-('7f r�(�
c-'Y�2-(3c-ro��'t� t-'vh t'hune ,•': `7'�f.. 7l�^40��
C i ty,State•%ip (,
.arc)uu an employer'?Check the appropriate box: 'Type or project (required):
I.❑ 1 am a empluyor with 4. ❑ I mart a -,cnural contractor and 1 6. ❑ New construction
\ cntpluyccs(full an&ur part-time) have hired the sub-contracture2. �• ❑ Remodeling
.lilt a sole proprietor or piratical- listed oil the attached sheet.
ship and have no cmpluyeus _ These sub-contractors have S. ❑ Demolition
Lurking lift me in any capacity. workers' comp.Insurance. 9, ❑ Building addition
No workers'cum insurance 5. ❑ We are a corporation and its
1 p• 10.❑ Electrical repairs or additions
I required.] officers have excrcned their
light ofexcnl tion per INGL 11.0 Plumbing repairs or additions
3.❑ 1 and it homeowner doing all work g P P'
myself. tNo workcrs' comp. c. 152, g 1(4),and we have no I2.0 Ruul repairs
insurance nyuired.) i employees. LNo workers' 13.❑ Other
romp. insurance rcyuircd.J
•)m .,Ipbaya that checks box it musi alai)Oil wit the,arbors Wow Allowing chill(wurkui cumpena ml lwlmy In iurrulium
' Ilumauwncn whu,ubinil this affidavit trial Ihu)+m Joins all work mid Ihcn Aim outside corurxtura must.uhmil a new ai'fdavil inJivarmy ,wh.
-f-,•mncu^Ihue shack this box most anaehed.m addoi.rlal nbeai,howina law uania of thus sub�onuaeiurs and their uurkan'comp pidlcy urflirmanun
/airs tin eurpluyer that i.t providing workers'euinpenytrtion inseerauce/or uey emplayels. Below is the puthy and job yiter
befuriuudy,m
Inmerancc Company Name:__-- - - -- - ---------
Puliev a ur Sclf-ins. Lic. r+: . .. __ Expiration Date:
Job Site Atldress: _._. City-state/zlp:
.Vlach it copy of ciao workers'compensation policy declaration page(slaewlnu the policy number and expiration date).
hallurc bi ,ccurc colerage as required under Section 25A ul'MUL c. 152 can lead to(lie imposition of criminal penalties of a
tine up to SL500.00 and/ur one-year imprisonment, as iccil as civil pc ialllcs in the I'arm of a STOP WORK ORDER and a fine
Of up ill i250.00 it JAY •Igaival the vi)lator. Re advised that a copy of Ihn ,iialcmeni may be Iurwardcd to the Office tit
Im:mn•,a mnu ul the UL\ :or io,m nice clnera�c 1 tiilic ul:tin.
/du herehy 1.rrify tinder the pain.and putulriev of perjary that the in/brina/Ion provided above Ii true and correcr.
i)/Jiciu/rue oily. Do not irritn in thit area, to he ruuipletrJ by city•ur town ujJiria/.
City ur h mn: _... _-- Per mitrl.iccrtse Al
I„uing .%ulhuriiv (circle line):
I. hoard of liv.Jih !. Ilrnlding Dcpartmcni 1. Cih."fmsu Clerk 4. L•'lectriotl ImI)ector S. Plumbing lu,pcetor
6. Other _
Cl,ntacl l'c nun: .. _ I'hone d:
Information and Instructions
\I.,oiaihu.ielts General Laws chapter I i2 requires all eugtlo)crs to provide workers' compensation for their employees.
11ursu.u❑ to this statute, an empluree is defined as " .every pcison in the service of another under any Contract of hire.
:.pre»or implied, oral Jr .vnmen."
An elnpluyer is defined as"an Individual, partner>hip, .Usocniliou, Corporation or other legal entity, or any two or more
J the foregoing engaged it a joint cnterprse. and including the Icgel representatives of a deceased empluycr, or the
feCer�ef Jr tN>lee Uf .al lrrdr Vldaal,pal suer>hip, assa:uuon or other legal comfy,employing employ ees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
,Iwelhng house of another who employs persons to do maintenunce,construction or repair work on >uch dwelling house
or ort the grounds or building appurtenant thereto>hall not because of such employment be deemed to be an employer."
]IGL chapter 152. §25C(6) also slates that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the communwealtb for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Xddiuunally. MGL chapter 152, 325CM states"Neither the commonwealth nor any of its political subdivisions shall
7 enter into any contract for the perfomtance of public work until accepuble evidence ofcutupliance with the insurance
requirements of this ehapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s) name(&), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and duce the affidavit. The affidavit should
Lie retuned it)the city or town that the application for the permit or license is being requested, not the Mpartment of
(ndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
('fly or'rown Offlclals
Please he sure that the affidavit is complete ;and printed legibly. The Department has provided a Space at the bottom
or the affidavit for you to till out in the event the Office of Investigations has to cuntacl you regarding the applicant.
Platnc be sure to fill in the pennittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current
policy infbrmution(if necessary) and under"Job Site Address"the applicant should write"all locutions in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file tnr future permits or licenses. A new affidavit must be filled out each
year. Where a home owner Jr citizen is obtaining a Incense Jr permit not related to any business Jr commercial venture
a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I hC i)(tire of hive\rig-ation> %%uuld Itne to thank )ou it% advance fur your Cooperation and should you have any quesfiuns,
,)lease du not hesitate to give us acall.
fhe Dcp.unncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations-- ---- ------- --- — ---
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..•I .. a; IJ: U ,d 11%i..,R<];tl l r • 1.\I I %t. \L�"v I .•_I•) _
Construction Debris Disposal .affidavit
(required lur all demolition and renovation work)
In accordance \%ith the sixth edition ofthe State Building Code, 780 CMR section 1 11.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
I (Ja _ -1.J y:S�—L
(name of hauler)
the debris will be disposed ofin
(name of lacdrtv)
Utz E.wac�>�
(address of facility)
'lunatWe of pernut .Ipphcaut
_31Zy kft
-
late