0055 HIGHLAND AVENUE - BPA-09-804 `i The Commonwealth of Massachusetts
Department of Public Safety
tiLtte Building Gude(780 CMR)Seventh F,dition
City of Salem
Building Permit Application for any Building other than a I-or 2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number Datr Applied: Building Inspector:
SECTION 1: LOCATION (Pleas indicate Block N and Lot M for locations for which a streAt address is not available)
I INXo.and Street Citc lTou-n Zip Code Mame of Building tit applicable)
SECTION 2:PROPOSED WORK
If New COn.truction check here❑or check all that apply in the two rows below
Existing BUildingX Repair Alteration ❑ Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans andlor construction documents being supplied as part of this permit application? Yes ❑ Na Q
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description Of Proposed Work: --7-�
f r�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): f'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft-)
SECTION 5:USE GROUP(Check as ap licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 8: Business E: Educational ❑
F: Facto F-1 Cl F2❑ 1 H: High Hazard H-1 O H-2❑ H-3 0 H-4❑ H-5 O
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile Q R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑
S: Storage 5-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION G:CONSTRUCTION TYPE(Check as applicable)
)A C) 111 FLA ❑ IIB IIIA ❑ 11111 E3 IV ❑ VA ❑ V8 ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal Trench Permit:
Debris Removal:
I .A trench will not be Licensed Dinposai Site Cl❑ ( heck if nut+ide H'40 Lune❑ Indicate nuuricipal ❑ requinal ❑Or trench nr�p
i't'H'Jte0 or mdtotly Zone:_.._ oron.tte,v,tem❑ ecih:
permit ix enclosed Q
I Railroad right-of-way: - Hazards to Air Navigation: ni-..on,Ro.I... Pro".":
\,,.t tole ❑ LStruClure truhm anpnrl opprnadt .trea' L. thea-revs e w CmtplvlciC
i t;�nei ni't'; 116111 rnd...rd a'--j t Ye.❑ „rNo0 11;❑ \„ Q
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
rtpcuf Cnnwt RlCtlnn. _ Occupant Lead per Ilam
I rur�the L ud.imy;Cnnta:n an S1,rinklrr Sr.Ycm': . Spvctai Stipulation,:
L�fCl � tt SECTION 9: PROPERTYOWNER AUTHORIZATION
ndressoPropertyOwner
nn 56 " gh `LJAV S � t ft
Name(Print)
Nu. and Street Cit.%/Town Ziipc,
r1%,"I 0%v ne Contact Information:
—� l Q35_ i4� 3 o 23o e CIL Ice
Title Telephone :No. (business) Telephone No. (cell) e-mail address
It a >�>I'g- ade, thr * aerh osv ner
L � hereaua
1 use
Q —._—
Name Street Address Cite'/ otcn State Zip
to act on the pro pert%.naner's behalf, in Al matters relative to avork authorized by this buiiddn >ermi[a +allcation.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
{it building is less than 35,Wti cu.It.of enclosed s pace and/or not under Cutistniction Control then check here O and kill Election 10.1)
10.1 Registered Professional Responsible for Construction Control
n c �ra t? ICM2E R
Na e(Re ri'tw Telephone e-mail tarj rens Registration Number
lis M7 o
Street Address CitV/Town State Zip Discipline Expiration Date
10.2 General Contractor
cU uNen C S Y0 3(o 2
X =Prrsu jZe .+'ibte_-fur Construction License No. and Type if Ap,Qlicable
Street Address df c City/Tow State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS CO%VENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes E3 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x_-_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $
Enclose check payable to I
5. Total Cost $ /P5, d'u/ (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv 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,
ecr
I'Ic,i�tiac ,not >i 'n Mitre p TiIIcluphonr.N�„t� Date
_�J A Ur
til nr 1 .— ('ihiTmatil titate Zip
I
,.....
Municipal Inspector to fill out this section upon application approval:
.Name Uate
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