259 HIGHLAND AVE - BPA-11-559 INTERIOR RENOVATIONS The Commonwealth of Massachusetts
Department of Public Safety
Nlas,achunetl,Slate Budding Lode(,80 CNIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwelling,
l This Section For Official Use Onlv)
Budding Permu Number: Date Applied: Budding Inspector:
AS ECTION 1:LOCATION (Pleasee indicate Block M and Lot N for locations for which a street address is not available)
No,and Street Cite /Town Zip Code Name of Building(if applicab e
SECTION 2:PROPOSED WORK
} If New Construction check here O or check all that apply in the two rows below
Existing Building Repair;lf I Alteration Addition❑ Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other W Specify: .T►J t C r:"r SLF L"OA¢ k
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: FQ.MCv� v'G.\\ '�:W xS� e r. �Onn )G4.$ <36,
l�N\ L.Ie Cie r )! \Z �c�Irh
�sc.cat. �-ac�'Js -rt S \\ it1�a \itl V
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): —75 Proposed Use Group(s): —
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.) 00 E♦
Total Area(sq. ft.)and Tutal Height(ft.) - VU 1 N' 1 �jiml All
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 X A4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Facto F-1 O F2❑ H: Hi h Hazard H-1 O H-2 13H-3 O H-4❑ H-5 E31: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4 C3M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage SI ❑ 5-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA)k IB ❑ IIA ❑ IIB ❑ IIIA O 1118 ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Nater Sup ly: I Flood Zone Infomtatiom n
Sewage Disposal: Trench Permit:
Debris Removal:
Put, C heck d rnn,lde Floud Z�'n' I I C. e n1ti tIX A trench wdl not he Licensed Ui,pus.d Site
Irryu ucd*ur trench ur,pcedc:
I'nvatu❑ lir ualentdc Ltnr:_ .rt.m,rte,v,tem ❑ permit to enclo,ed ❑ _
I Railroad right-of-way: Hazards to Air Navigation: \I:\ I h,l•ve c .annm�nn Hn inn Pr„r”:
Va AI•phc.d•le 1,sirui lwt•n 1111111 au pwlappo.ichorvo' I,lhc❑retletc ruin l'Ic led'
• r( „11.x111 In l4udd end...ed ❑ le,❑ nr.N,. 14•,❑ \o ❑
j SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
Lddwn .•I ('udr S\ } l�e llruuia.c �' Rpc ul t'un.tro.Uun: _1 c� ticcup.uu Loud I,,r I lu,,r
U„v, lhr buddutr;omlam.vt Sl+nnklrr�t,tem': V� �prc ial Stipulahun, _ _
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro+eel%Owner
Swc:ww`5cJ'i� Hca\b� \�C LOO V-09- Of,� Ave- SJR\ern_ i�\,4- 01 `l0
Name(Print) : 'o.and Street Cih'/Town Zip
Properly 0%,tier Contact Information:
ctA 191 -�l7 cz�r�,1. o,•.
Title Telephone No.(busmess) Telephone No. (cell) e-mad address
Ifap•Itc.ible, the property owner hereby authorizes
ACA
Name titrert Address City/Town State Zip
to act on the •ro ert% ,+%tier's behalf, m,dl matters relative to work outhunted by this builaiin • +rrmrt a +lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
(lt buildin g is lass than 3i,L%)Uan. IL ul rnduvd 5 race,Ind/Jf❑JI Und%r I_Un>trUa'hJn CJnWI Iha•n chKk here and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company sT
Na e:
I�c> - � k6a CS\- SG�f-Ib �wces�; ec�
Name of Perwn Res)xrnsibje for Construction License No. and Type if Applicable
i\ \30,:k\e�+ _14�rsba rte. She _ 01C' I
Street Address City/Town State ,5Zip
�-�- Otto (,f? -�- iso% Mr-0C\rQ,,.) � In kC �cassf 4C-01V\
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Cumpensation 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 denialof[he issuance of the building permit.
Is a signed Affidavit submitted with this application? Yea 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 $ oQ appropriate municipal factor)_$
3. Plumbing $ Lp
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $ P Y)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ g coo (contact munici alit )and write check number here
SECFION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
applied wn is true onat accurate to e bra ul y k osyledge and undemanding.
j i i7/' ofc
Mary (7.�cc�nor i 7uponapplication:approv7al:
Cot akCC-AC)r (n.�f s 6
I'le.r-c pont eI . n...netitle TOL-phone\,. Ualu
\\ 6o c \ems- ''lace., Sh�� Mc. V 113
,tNcvt lddrv— Ut%;'T,.wn },
me F
i
Municipal Inspector to till out this _
Pate