0040 REAR HIGHLAND AVENUE - BPA-86-13 f . 1� •�
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�,� The Commonwealth of Massachusetts
^ � Depaztment of Pnblic Safety
�I_ Massachusetis State Building Code(7S0 CMR)
L,� Bnilding Petmit Application for any Building oth�tk�an a One-or Two-Family Dwelling
� ('R�is Section For Official Use Only)
Building Permit Number: Date Applied: Building OHicial:�
SEC'I'ION 1:LOCATTON(Please indicaM Black#and Lot#for locaHons for which a sheet addrass is not available)
G/l/� �`�a��,�� �'� SitzEm m�'+ o/97D �=,�i��rFn7�;FE' /�fP7s
No.and Street � . . City/Town Zip Code Name of Building(if applicable)
� SECTTON 2•PROPOSED WORK
EdiHon of MA State Code used_ IF New Construction check here O or check all that apply in the two�rows below
Existing Building❑ Repa'v❑ Alteration C�' Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Qmipancy ❑ OFher ❑ Specify:
. Are building plans and�or mnstructlon documents being supplied as part of this permit application? Yes ❑ No ❑ . ,
Is an Independent SW ctural Enginee ' g Peer I;eview�uired? . "�� Yes ❑ No ❑
Brief Dcscxiption of Proposed Work: �r<'C / [�' P�CiJ�l7 /�n-�anqa w�7�/i iv noc .
p� L,4� �,„n .9DJ,-i6 /Is'� iilEx � C.�r.3Lc . .
SECTION 3:COMPLETE TH[S SECTION IF EJCISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an E�dstmg Building Imestigation and Evalnadon is enclosed(See 780 CMR 34) �
Existing Use Group(s): Proposed Use Group(s):
SECTION 4 BUILDING HEIGHT AND AREA �
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.R)
Total Area(sq.ftJ and Total Height(k.) � 9� � ��
SEC7TON 5:USE GROUP(CLeck as applicable) � � II
A: Assem6ly A-1 ❑ A-2❑ Nightclub ❑ A3 ❑ A 1❑ A-5❑ B: Bnsiness ❑ E: Edneational ❑
F: Facto F-1 ❑ F2❑ H: H' L Hazard H-1 ❑ H-2❑ H-3 ❑ H�❑ H-S❑
I: [nstitaflon�l I-1 O. I-2❑ I-3❑ I-4❑ M: Merrantile❑ R Residential R-1❑ R-2❑ R-3❑ R11❑
S: Slorage Sl ❑ S2❑ U: Utility�' ii .i Special Use O and please desciibe below:
Special Use:
SECITON&CONSTRUCTION TYPE(Check as applicable)
IA O 1B 0 IIA ❑ RB ❑ r IIIA 0 IIIB 0 IV O VA O VB 0
SECT[ON 7:SITE INFORMA7'[ON(refer ro 7S0 CMR 111A for de[ails on eacl�ibem)
Water Supply: Flood Zone Information: Sewage Disposal: T��P�n��t Debris RemovaL•
Public❑ Check if ouLside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentiCy Zone: or on site system❑ rcquired O or trench or specify: .
pemiit is enclosed❑
Railroad rightof-way. Ha�ards M Air Navigation: n,sa u�z��,::.::':.....::-:_,.:....�� .:... 7'...,.�_.: .
Not Applicable 4Y Is Structure within airport approach area? Is their review mmpleted?
or Consent to Budd enclosed❑ Yes O or No CZ—� Yes❑ No ❑
� � SECTION&CONTENT OF CERTIFICATE OF OCCUPANCY
Ediflon of Code: Use Group(s): Type of Construction: Oecupant Load per Floor.
1Joes the building mntain an Sprinkler System?: Special Stipulations:
� C�� 339-�� -�'���
� . � � 'SECTTON�9 PROPERTY OWNEA AUTHORIZATTON I�
Name and Addr2ss of Prciperiy Owner
�jrj2�cr�yj�z �/lSU✓R'71uN �N$� 3I0� t3i�.,�y SEc I 234 kG��s �'. � ' MG �y//1
. Name(Print) � No.and Street City/Town 7ip
Property Owner Contact Inforsalion: -
Tide � Telephone No.(business) Telephone No. (cell) e-mail address .
If applicable,the property owner hereby authorizes
_ Name StreetAddress City/Town . � �State Zip
to act on the ro owner's behalt,in all matters relafive to work authorized b this buildin mtit a licaflon.
��� SEC7'[ONIQCONSTRUCITON�CONTROL(PleasefillontAppendix2) �
If btildin is less N�an 35,W0 cu.ft.of enclosed ace and/ox not undex Construction Control then check hem 0 and s}a Section 10.1
10.1 Re isfiemd Professioaal Res onsible far Construcflon Control '
C�74 !�'/D // �iJfinslii�l4 �FT�./(�/ _ �/O� . y7Z � �
r
Name(Registrant � Telephone 7N7o.� rmaIl address RegistraHon Number
7U/ i3os�an �o9E �� n/rst /�a�/bO�o,.�G� /N/V' 0� 7� 2 C? .�i'�
Street Address Gty/Town State Zip � Disapline Fxpiradon Date
1Q2 General Conh'actor -
�LZE /'FC S�JC�c}c C .
Company Name � � .
C-tv�—,=- .�-�5� 9 s�9�y
Name of Person Responsible for Construction License No. and Type if Applicable
/a lve5crrciT /�D �E'*��-rG �
Street Addmss City/Town Slate Zip
��32_ o!Z Z =_
Tele hone No.(business) Tele hone No.(cell) rmail addmss
SECTIONII: � , . ........ . ..._..-...,.°.°"•" ,,.,•,,•.,• .G.L.c152§25C6
A W orkers'Compensation Insurance Afftdavit from the MA Departm�t of[ndustrial Acadents must be mmpleted and
submitted with this applicaHon. Yailure to pmvide this affidavit will result in the denial of the issuance of the building permit.
Is a si � ed Affidavit submitted with this a lication? Yes� No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor I
and Materials) Total Consfruction Cost(from Item 6)_$
1.BuIlding $ /��O D U
. � Building Perntit Fee=ToLal ConsW ction Cost x_(Insert here
2.Electrical - $ appmpriate municipal factor)_$
3.Plum6ing � $ - .
- 4.Mechazu�l (HVAC) $ Nofe:Minimum fee=$ (mntad muniapality)
5.Mec3�anical (Other) $ Enclose check payable to
6.Tohal Cost $ ��� OOG (mntact municipality)and write check number here ��
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all bf the information contained in this
applicatlon is true and accurate to the best of my knowledge and understanding. - - � �
��c �at �� /�/c+�.c /��u`ii. �i1���ll� �5�-,/ ;�.- �.nvt.�t 3�9 _fr3Z _06?2 7/6-/2
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� Please print and sign name Title Tele ne No. Date
� �3 �02f5T ST. /r��ricc/3o�or>FsN � di
Street Address � City/Town Shate �
Municipal Inspeclor to fill o¢t this section upon application approval: (
Name Date
* r
� L �
� Appendix 1 �
For the demolition of structures the building permit applicant shall attest that utility and other
service connecrions are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building pernut
application. The building permit applicant attests under the pains and penalties of perjury that
the foliowing is true and accurate.
Property Location (Please indicate Block# and Lot#for locations for which a street address is not
available) "
��D�i �5h ��� S �Pm /YI�A OI c/7v ��ic./P�Y'�'/
No.and Street � City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken: � ,
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No � Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
..
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Appendix 2
Construcdon Documents aze required for structures that must comply with 7S0 CMR 107.The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered pmfessionats
responsible for the documents. This appendix is to be submitted with the building permit
application
Checklist for Construction Documents" /
Mark"x"wLee a licable
No. Item Su6mitted Incom le6e NotRe nimd
1 Architectural �
2 Foundation
3 Structural
4 Fire Su ression
5 Fire Alarm(ma r re aters) �
6 HVAC
7 Elxtrical
8 Plumbin (include local mnnecfions)
9 Gas(Natural,Pro ane,Medical or other)
10 Surve ed Site Plan(Cltilities,Wetland,etc.)
ll 5 ' icaflons � .
12 Structural Peer Review
13 Structural TesLs&Ins tions Pro am
14 Fire Protection Nazrative Re rt
15 F�cistin Buildin Surve /InvesE a[ion
16 Ener Conservation R ort
17 Architectural Access Review(521 CMR)
18 Workers Com en.sation Insurance
19 Harardous Material Miti ation Documenta[ion
20 Other(S " )
Zl Other(S iE )
22 Other(S � )
`Areas of Design or Construction for which plans are not mmplete at the tiure of appli�tion submittal must be identified herein.W ork
so identified must not be mmm�ced until this applicallon has be�amended and the proposed mnshuction docvment amendment
has been appmved by the authority having jurisdiction.W ork started prior to approval may be subjected to tripk tite origina[qermit
fee.
Registered Y'rofessional Contact Information
C/,� ��.-�i���i,� 5(�b—_yF/ _7uc>o . �/ 7 ?9'3
Name(Registrant) � Telephone/No. e-mail address Registration NumUer
Zo! �r�bN ��{ R d /`la��bo/c�5� irlw O/>s L •✓� /
Street Address - City/Tocvn State Zip Discipline ExpiraHon Date
Name(Registrant) Telephone No. Pmail address Registration Number
Street Address G /Town State Zi � Disapline Expiralion Date '
IVame(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci Town State Z� Discipline Expiration Date
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� .i Uass:�chusctlz- Dcp:u-tmrn� ul'Public S:ifcn � �
. . , � . Bu:u�d uf'Buildin� Rc�uL•uinns and Slandards `
� , Construction Supervisor License !
- �icense: CS 98919 ' I
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GEOFFREY FORSE �"; � i
- 1D WESCROFT RD �
READING,�MAOi867 ' �'�s� I
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��� -y�`� Expira[ion: 5/4/2013 j
(1+nnniseiuner Tr': 13683
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. Failurc to pussess a current edltion of the
Mnssachusetts Stnte Boildieg Code
. is cause far revocation af[his license.
* � Referto: WWW.Mass.GovlDPS �
� Th¢CommonweattA ojMassachusetls �
Department ofladusirial Accldents •
Offcce oflnvestigations
600 Washingtan Street
Boslon,MA 02111
� www.mass.gov/dia
. Workers'Compensation Iosurance Atlida�it: BuilderslCantractars/Electricians/Plumbers
Aoalicant Information Please Print Leablv
N3iIl0(Busincss�Organi`AUo*�nndividual): �LLZ� �f"S Suc� c +�S .
Address: � 5 3 �v✓�s a s}"
City/StatelZip: uti �- ���-� � � M/� �i�+Z Phone#: 3 3 5 - &-3 z-c� z Z
Ne you an employer?Check t6e appropriate boz: Tppe of projec[(required):
1.[a'�am a employerwith S� 4- ❑ 1 am a general wntractor and 1 6, �New constmcfion
employees(full and/or part-time).• have hired the subcontcactors
.2.Q I am a sole proprietoror patmer- listed on the amched shee[.i �- ❑Remodeling .
. ship and have no employees 1'hese sub-conhacmrs have 8. ❑Demofirion
wwking for me in any capacity. workers'comp.ins�aance. g, Q guilding addiIIon
[No workecs'comp.iasu�ance � 5. ❑We are a co=poration and its 20.❑Elec4ical repairs or additions � �
� ����� officers liave exacised their
3.❑�T am a homeoava doing al]work � ��8tit of exemption per MGL� 11.❑Plumbing�epairs or add,itions
myself.[i.'o arorkers'comp. c.152,§1(4),and we have no 12.❑Roof repai�s
insu�ance required.j* employees.[No workers' 13.❑Other
comp.insurance raquie�ed.)
°Any�licam�hat chaks boz#1 muff dso 611 ou[llve aectlon bdow ahowing Neir mo�kers oompc�erioupeliry infmmation.
t Homrownas wlm submit ihis aiFdevn iMicaung dtey arc doing all wmk and 1firn Ime outside couYacmrs must sub:nit a new alltdarit indicam�g such.
�CanlaMn�hn�eheck ihis box must atmclN m�aAdiuorel shett s6owing thc name of�hc mbcoemumrs and their warkas'mmp.policy infwmaam.
!um ux emptoyer thatu providing workers'compeasalion lnsurnnce far my emplayees. Brlow is Hoe poticy anAjob ufe
injormatiom �^
Insurance Compa�y Narne: � � ��5 �
Policy#m Seiftins.Lic.#: L✓ C j � 5 '7�'U � 3 Expuarion Date:��—z � ' /3
lob Site Addresr.�OOL �7��',� City/State/Zip: S�!-� h� �
Attach e copy of the workers'eompensatlon policy declaredon puge(showing the policy numDer eud espiratlon dete).
Failurc to secme covernge as required undet Section 25�1 of MGL c. 152 can lead to the imposition of¢-iminal penalties of a
fine up to$],500.00 and�or one-ycar imprisonment,as well as civil penalties in the fonn of a STOP WORK ORDER and a fine
� of up to$250.00 a day agains[ffie violator: Be advised that a copy of this statement may be Forwarded W the Of£ice of
� investigations of the DIA for insmance covera@e verificarion.
!do hereby ce�/fyj�e�/nder the palns and pendties afperjury that the informatiort provided obwe is bue and carrect
Sianamre� /'/ /�. �i i /F ���L Date� �—��' �7
PhoneH: �3 S '� E 3 2 —O(� Z Z
Officia!ure only. Do not write in t/us mea,to be completed by ciry or town afjtcial
City or Town: PenniNGicense# �
Issuiog Authoriry(circle a�re): � �
1.Board of Health 2.Building IJepariment 3.City/Town Clerk 4.Flectricat laspector 5.PlumbingInspector
6.O[her
Contact Perwn: PLone#:
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1
� � ` Client#:56697 JLEEA550
s�OC�dl�.,. CEC�TIF9Cee.TE O� LIA���I�Y IN�190.ANCE onrelmm�omrr�rl
5lWl20t2
THIS CER7IEICATE IS ISSUED AS A MATTER OF INFORIYIA710N ONLY AND CONFERS NO RIGH7S UPON THE CERTIFlCATE HOLOER.THIS
CERTIFICATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AMENO,EXTEND OR ALTER THE COVERAGE AFF�R�EU BY THE POLICIES
6ELOW.THIS CERTIFfCATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BE7WEEN THE ISSUING INSURER(5),AU7HORIZED j
REPRESENTATIVE OR PRODUCER,AND THE CER7IFICATE HOLDER. � �
IMPORTANT:If the certfficete holder Is an AODRIONAL INSURE�,the poilcy(lesj must 6e entlorsed.Ii SUBROGATION IS WAIVEU,subJeG ta • �
the terms and condkions of the pol3cy,cartaln pollcles may requim an endorsement A statement on this certifreate does not confer rlghts to the
� aertlflcate hnlder In Ileu of sueh endarsement(s). ' �
PflOOUGER � CONTAGT Maria Bamowski
N0.ME:
Starkweather 8 Shepley � "noNE q09 435-3600 �" A01 437-9326
uc,r�o.ai: ac nor.�
PO Box 549 a�p�s: m6arnowski@starshep.com .
Provltlenee,Rl OYBO�-OS4B INSURER�S�AFFORDINGCOYERAGE ru�cz �
441 4353840 �HsuqE,,,,:First Financial Ins Co/RTS 11777
�N�+R� �xsu�ae:RSlll Indemnity Co/RT5 2231A
J.Lee Associates,Inc. Chartis 26583 �
INSIIPEA L:
753 Parest Streei . � �Nsu�an:7ravelers Insurance Company 25674
Marlborough,MA 07752 �
INSIIRER E:
INSORER F'
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY TNAT 5HE POLIGIES OF INSURANCE LISTED BELOW MA�EBEENISSUED TOTHE INSURE� NAMEOABOVE FQRTHE POLICYPERIOO
INOICATED. NOTWITHSTANDING AIQV RE�l11REMENT, TERM OR CON�I'fiONOF ANY CONTRACTOR OTHER OOCUMENT IMTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN,. iHE INSURHNCE AFFOR�Eb BV THE POLICIES �ESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCWSIONS ANO CON�ITIONS OF SULH POLIQES. LIMITS SHOWN MAV HAVE 6EEN RF�UCED BY PAI� CLAIMS.
INSR /09L t19fl � � POLICYEFF POLILYEXP
LTfl n'PEOFINSIIRANCE IINSH 49V� POLICVNlIMBER MNIOOlY1'YY MMI�D�YYYY UMITS
A GEXERALLIABILiTY NGL0030847 MZSIPO'IY OAJYBIYO'I �GACM OCCURRENCE 5'I OOO OOO
X COMMERCIALGENEFPLU/BLL1TY � O ENTE[1 I
Bh�r�u sT���Ro�� s100 ODD
ClAIMS-MME �OCNR MEOE%P(MYo�c cr.w� SO I
PHi50WLL&ADVINJURY 5'I�DOO�OOD
GENERALAGGREGAiE SZ�OOO�O�O
C�NiAGGREGPTEIIMRAPPLIESPER: PRODUGTS-GOSiPfOPAGG SZ,OOO�OOO
POIJCY X �6 LOC 5
p autamoeaeunsiurr Bq78058756 4/28l20t2 04/28/201 EaM�IN�E0t51NGLELIMR S�,OOD,000
AWVAUTO 600RYIt1LUaY(vmper:vn) 5
ALLO'MIE� � SGHEOULEa BOo1LVIN.IUPY(Peraccitlenq 5
AIfT05 N11T05
X HIREO AUTOS J( NON�OHME� PftOPERTY DAMAGE 5
AUTOS PerucoJenl
5
B ( � UMBRELLALIAB X accua � NHA059737 4/28l2012 04128/20i3ena+occuasence s5000000
EXCESS LIPB CIAIMS-MPOE AGGFEGATE SS QOO OOO
�ED I X FETEMIONSO 5
WOftI�RSCON�EN9AT10N wGSTATU- OTH-
C � WC013979015 2126/2072 02126l2U73' �
ANO EMPLOYERS'LIA6ILITY
qNYPROPRIEfONIPARTNERIE]�GIILiVEY'H E.L.FACHACCmENt SIOOUOOO
O�IGEWMEM9ERE%CWpEOi � NlA
�MaekateryinNX) E.L.Oi5Ea5E-FAEMaIOYEE S� OOOOOO
I�ESLR�TI NOFOPEflA110N5below IE.L.OISLASE-POLIGVLIMIT 5��0�0.���
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UESCRIPTION OF OPER0.]IONS f LOCHTION41 VEIOCLE91>nnen q�OPO 16L AEtlitivnal RomatNs Seh¢dulo,If mom.paen L-teqvlmtl)
CERTIFICATE HOLDER CANCELLA710N
SHOULO ANY OF THE A80VE OESCR�EO POLICIES BE CANCELLED BEFORE
� TNE EXPIRATION OATE THEREOF, NOTIGE WILL BE UELIVERED IN
-- ACCORDANLE WITFI THE POLfCY PROVISIONS. -
FUfH0Al2E0 RFPPESENTATIVE
`7nqru.ci. ao. Ganma��.;
� O 1988-2010 ACORD CORPORATION.All rights reserved.
ACORO 25(2�10/05) 1. p(� 7he ACORO name antl logo are reglsteretl marks of ACORD
� NS391815lM390337 MBB
;: .° CITY OF SI�I..E��i, 1�T�-�SS.�CHL'S�TTS
BLu.n�'G DEPiRZ.ItE,VT
= 130 W.isHL�tGTOH STR£ET, 3'O Ft.00R-
� �'l T�.. (978} 7-15-9595
FA.�c(978) 74Q-9846 •
K[�fgERI�Y DRISCOII. .
LLIYOR ll-IO�i21S$Y.PtERRE
I7IRECTOR OF P1;BI1C PROPER'IY�Bt;II�I�:G CO<L\SISSIO�i£R
Construction Delbris D'aspos�� �lffidavit ,
(required for all demolition ;uid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 t.5
Debris, and the provisions of MGL c 40, S 54; �
Building Permit# is issued with the condition that the dcbris resulting finm
this work shall be disposcd of in a properIy licensed waste disposal facility as defined by MGL c
l 1 l, S i S�A.
Thc dehris will be transpartcd by:
i�/o /7 c�0 5
(nvme of hauler)
The debris will be disposed of in :
(name of facility) ,
(address of fucility)
�1�.! �/c
' sienatu[e Of permit applicant
�
. . 7—��—/2 -
date
dcbriuit�.J�x:
, ;� °, �IT1' OF S��1LE:Zi, I�IASS.�CHI;SETTS
' ' � Bi:IIDt\GT�EP�R'['1fE.�iT �
� ' 1?0 W�.iH�cTo�v STxEs'r,3'°FLooR
\ �j "!'EL (978) 745-?595
• F.1.�c(978}i�f0.98�i8
KI\iSERIEY DRTSCOLL
�YOR � THoelas S'i.PlEateB
DIKECTOR OF PCBLIG YROPERTY�BCIIDL\G CO�L\IISSIO1iER
Workers' Compensation Insurance AtTidavit: DuiiderslCuntractorsiElectricians/Plumbers
ann�scant information Plcase Print Leeihlv
V,�q7C(Dusi�xsviOrSanizatioNtndividual�: •
A(I(IfCSS:
CitylStatc/Zip: Phone#:
:►re you an employer°Check the apprupriate hot: Type of pcoject(required):
1.Q I am a unptoycr with 4. Q 1 atn a gea�7a1 contraclor avd 1 4- ❑New conswc[ion �
emplayees(fittl aadlor part-lime}.• have hired[he sub-cantracmrs
2_Q I a�n a so[e proprietor or partner- luted oa the attached sheet� �� ❑aeAiOtlCliug
- +h�p anJ have no employena These sub-contrac[ors have S. ❑nemolition
wnrking fiu me in;my capacity, �vorke�s'comp.insurance, q_ �6uilding additioa
(ho worke[s'comp, insurartce 5. Q We are a corpornpon and ia
mquired.] �
officers have ezemised[heir �0.0 Elec[rical repairs or additions
3.� i am a homcuwncr doing ail work cight ofcxemptiun per MGL 11.Q Ptumbing rcpairs or additions
myself.j\o workers'cmnp. c I52,�I(4),and we have no �Z,�Roof rcpaus
insurancareyuired.]� emp]nyers.[ido workers' �3.[]Other
. rnmp.incurance requin.�d.j
'nnY applicam that ch�,cks huz SI must aiau fill uut Ihe secliuo bclowshowing iheirwmke�i eompenaa4on policy infurmalion.
*IL.menwne�s whusuM�it�his affiAavir:rtdinting ihry are doing all woticand thm hve outsidecronuattvrs�mnt suMmit a nexr a�Javif indiati�weh
=Cnmrw�wn thni�iuek rhie box mwt unached art�ditiuNl nha�showing ihe avne ol�he rub-eonlrecto�s and their wuAcm'eomp,yulicy infamu�iaq,
I um aa emp(ayer rhat is providrng ivorkers'compensatian ensuronce jor my erapioyeex Below Is�he poticy nnd fob si�e
injorm(uinn.
Insurancc Company Vame_ ,y
Yolicy H ur Setf-ins.Lic.N: � Ezpiration Date: �
!ub Sice Adclress: CirylSca�Zip:
,�ttacd a copy of the�vorkers'campcasaGon poflcy declarat2an page(showing the poitcy numbor and e:piratloa dat¢�.
Failure to x:cure coveroge as required ander Section 2iA of MGL c. 152 can lead to the imposition oferiminal penaltiea of a
fine up to S 1,500,00 and/or one-year imprisonmcnE as weil as civil penal6cy in the form ul'a STOP WORK ORDER and a fine
of up m 5'SO.OQ a Juy agains[tht violntor. 13e advi.ecl that a c:opy oF this statement may be forwarded�o Ihe Oflice of
Invcstigation.uf thc DIA for insurance covcragc vcrification. .
I da hereby certijy uedrr ihe pnins aud penaffies af perJury that t!u iufurmatiae proviJrd a6ove is lrue und correct -
Si����rt�irt: Da[c:
� Phune.Y: �
OJjrcia!use mdy Du not w�ile in this urru to be can+plRed by city or lown ojJirruL
City or Ta�vn: , , . PermiHl.icenae#
Iuuing Aulhurily(circic unc): J . . �
. 1. ISo•rrd u(1[ealth 2_Ruifding Dcpartment J.Citylfo��n Clerk a. Electrical Inspecto[ 5.Plumbing Inapector
G.O(her .._ ..,_
Cnntact Pcrwn• . .__ Phone#:
1 i
, ° ` CITY OF S.'�LE�I, �"I��SS.�CHLSETTS
Bti IIDL�iG DEP�R'I1�,�iT
• � N• l?O W.iSHL�IGTON STREE7, 3°O FLOOR
`\ '�a"J 'IL'i_ (978) 745-9595
F�s(97� 7�10-9846
,{��{gElti.EY DRISCOLt.
V[roYOR "I1�ioMAs ST.PIExxE
L?ITtECTOR OF PL"BLIC PROPERIY/Hl:W?LtiG CO�L\SiS5i0;iER
CO\STRUCTIOti CO�iTROI.DOCtiyIEYT
Project"Citie: ��____ � _ Date: _
Projec[Location: _. ,. __�___-.__.
Scope af ProjecS: _ . . _ _ __ �_�
in accordance with SEC1'[O�I [16.0-I IG.4.2 ofthe 6th edition of the Massaehusctts State IIuilding Code :
I,_. _ _ ldass_ Rcgistradon Number __.
� being a registered professional Lng:neer/Architect hereby CERTIFY that I.have przpared or din.�ctly supervised
the preparaAan oi'all design plans, compurarions and specifrca6ons conceming:
[ � Entire Projeet [ ] A�chitectural ( ] Structura3 [ ) Vteehanical
[ ] FirePro�cction ( � Cl::ctrica( [ J Other(specity)
for the above namcd project and tUat to thc bcst of my knowlcdge, such pYans, computations and specifications meet
the applicable provisions of the titassachusc[ts S[ate Building Code, all acceptable engineering praciices and all
applicable laws for the proposcd project.
Purthermore, I un�erstrnd and Af,l2EE Ihat I sha31 perform the necessary professional services and be present aa
tUe constructio��s-ite on a cegular and periodic basis to detecmine that the work is proceeding in accordance with d�e
ducuments:�pproved by the building permit ard shatl6e msponsible for the following as specitied in section
I IG.22:
1. Review ot shop drawings,samples and other submittals o£thc contractor as required by the construcfion
contract doeuntenu as submitted for the bui(ding perenit,and approval for the confonnance ro the design
concepY. � � '
2. Review and appruoal of thc yuaiity contro]procedures fot all code-requirc�i controlled materials.
� 3. 6e prescn[at inte�va[s appropria[e to che stage o£coushvction to bccome generally familiaz with
Qie progress an�i quality of the wark and ro deietmine,in genecal, if the work is being petformed in
a manner cc�nsistent with the conswctian documents.
f shail submit periudically, in a form acceptahle to thc huilding ot3icial,a progress report together with pertincnt
comtnents. Upop complelion of the work, I shall submit ro the building oEficiat a fnal report as to the
sa[isfacrory completion and reatiiness of thc project for occupancy.
- Signature and Sral of registered protessionul:
40 REAR HIGHLAND AVENUE 86-13
Grs#:�"�� "". �aa � "; , �,' �� COMMONWEALTH OF MASSACHUSETTS
t, .. Map: : . 25 � ';
' B�o�k: :� : . CTTY OF SALEM
�, ;.'Lot a'.- 0019 � = -
?° Category ;� AnCennas " �r �'� ��
Pemvt# �"` 86 13 ���' � �� � ��� BUILDING PERMIT
Pro�ect# �: „''-JS-2013-0004�3
Est:Cost:,�`�,' $14,000 00 �.
Fee Charged:'„;� $159.00 ��
Balance Due:"G $.00= 'ta�� �� ..-�, ��' PERMISSIONIS HEREBY GRANTED TO:
Const Class:k_ i� '" "� `Contractor: License: Expires:
Use Group:.�: ; .��y_� � .�.'�Center Line Communica[ions/Peter Moro
�ot Size(sq:ft). 300564 �,�!. .` ^�"Owner: FAIRWEATHER PRESERVATION ASSOCIATES LIM PARTNRSHP, C/O
Zoning �`�vF R3 � �In :
Unrts Gained:�.��,� �,� _��x� �: �.�� ? .:'AppliCa�tt: Center Line Communications/Peter Moio
Umts Lost: �;,;,,' � s=.,� ���, `_ °.-��;AT: 40 REAR HIGHLAIVD AVENUE
Dig Safe#: � ' �"
ISSUED ON: 31-7u1-2012 AMENDED ON: EXPIRES ON: 31-Deo2012
� :�� TO PERFORM THE FOLLOWING WO . �
. REPLACING(6)EXISTING ATTENNAS WITH N ENNAS IF MQ�E�NFORMATION IS NEEDED PLEASE SEE
PERMIT APPLICATION(AS OF 10/5/12 THE A O E EW CO�d7�I2A�OR IS DOING THE JOB FROM START TO
FINISH)jbh ;� �Y
.
POST THIS CARD O I S VISIBLE FROM THE ST ET
Electric Gas umbm ' � �, . uild'
Underground: Undcrground: UnJur ro nd: av ' .
Service: Meter. ^ �� �p� Footings: _ ���
Rough: Rough: Rough: (/�{�('�, rJ Foundation: V
Final: Final: Final: / / �rame:
� Fireplace/Chimney:
D.P.W. Fire Health
� Insulation:
Metcr: Oil: �
..;:i• Final:
;��:`€ Housu# Smokc:
.v
Trcasury:
- � Water: Alarm: Assessm'
� Sewer. Sprinklers: Final:
TffiS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIO -�ION OF ANY OF ITS
RULES AND REGULATIONS.
' � � Signature:
Fef�'�Tp�,t_,��,,, Receipt No: � Date Paid: Check No: AmounC
Bc�B�rt�rez,E ��.�;_, _ � __ "aE�2o5��doae9 sia�i-iz s�z $�s9.00
CONSTRUCTICN.S�� r � G.�:: � -%UIiING .
- .. �. .....�-:3 CODE
CHqPTEF 1 fOR L!:.� ��
CALL 97b.619 5tia I 1 U oi.�ycU..�,_:�... �r:s"rcCTOION
� CeoTMS�2012 Des Lauricrs Municipal Solutions,Inc.
,u:;
. PeterMoro pmoro@dinellc.com � � .
Superintendent P.50&989-1510��F.6V-2qgpgi9
95 Ryan Drive Suite 1 � Raynham,MA OD67 �
CENTERLIN�MMUNICATIONS LLC
��
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�EE
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ASSOCIATES
October 2, 2012
Thomas J. St. Pierre
Inspectional Services Director
City of Salem
120 Washington St., 3rd Floor �
Salem, MA 01970
RE: T-Mobile Telecommunications Installalions
40 Rear Avenue
Sa[em,Ma 01970
Dear Mr. St. Pierre,
This is authorization to allow replacement of the existing contractor, myself Geoffrey D. Forse on
the issued building permit number 86-13 for site located at 40 Rear Avenue Salem, Ma 01970.
The new contractor taking over the construction site will be: Peter Maro; Centerline 95 Ryan
Drive Raynham,MA 02767.
Sincerely,
Geoffrey D. Forse
753 Forest Street Marlboro, Ma 01752
Phone: 508 597 1330 Fax: 508 597 1335
�
� ",'�tTi%Z63
40 REAR HIGHLAND AVENUE 86-13
�cis s� `-,i?ga .— COMMONWEALTH OF 1VIASSACHUSETTS
�Map_ IZ.S - .�
;aro�x: ; � CITY OF SALEM
�Lot.-- 10019 , � I �
Ca[egory Antennas : , , �
�Pe==„�t# �g613 BUILDING PERMIT
, -�
;PrujectN'_';";��;?':-J$-20I3A00453 �
'Est.Co&fi.':"��-`.� $14,000.00 � .
'Fee.Charged _��� $159:00 ' . �
Balan�e Due: ' S.00 PERMISSIONIS HEREBY GRANTED TO:
�----r — - -
_
� ��Const.�Class: . � Contractor: � Lice�ase: Expires:
Use Group � J Lee Associates,inc
. ._ .—___. .
Lot Size(sq ft.)300564 �
�-�- �— � � ----�-Oivrter: FAIRWEATHER PRESERVATION ASSOCIATES LIM PARTNRSHP,C/O
"Lonmg: IR3
�Units Gained: Applicaitf: J Lee Associates,Inc
�Units Lost: '� AT: 40 REAR HIGHLAND AVENliE
;Dia Safe#:� j
I.SSUED ON.• 31-7u1-2012 AMENDED ON.• EXP7RES ON.• �i-Dec-2012
TO PERFORM THE FOLLOWINC WORIG
- REPLACING(6)EXISTlb'G ATTENNAS WITH(6)ANTENNAS IF MORE INFORMATION IS NEEDED PLEASE SEE
PERi�IIT APPLICATION jbh -
POST THIS CARD SO IT]S VISIBLE FROM THE STREET
Electric Gas Plumbin Buildina
Gnderground: Ontlerground: � Undergruund: Excnvatinn:
Senice: Meler: F'oo[ings:
IRaueh: Roueh: Kough: Nuundntion:
''�FinaL Final: FinaL' Rough Frnmc:
. . Fireplace;Chimuey: I
ll.P.��-. Fire fiealth
[nsulatinn: �
)Icmr: Oil: - '
Finul: �
�Houu= imokr. �
Treasury: �
«a[er: :llarm: .a55e55o1' ,
Se..er: SprivWers: Finah � . .
1"ffiS PEItA7IT il�AY BE 12EVOKEll BY THE C1TY OF SALEM UPON V~�'r1'ION OF ANY OF ITS 1
RLZES AND REGULATIONS. — k
Signaturc: � � �
FeeType: s, IteceiptNo: UatePaid: CheckNo: AmounL �
BUILDINGF:=;T_' _' nn��-"2663�8(3Q3GQi.:,,.� 34Ju412 3l2 Sli9.00
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License: CS-081072 ,�
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PETER R M�Ita � �` �
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�const c lass � -_. . -. .
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�Oni[� (lained -���A�l�ltennt: CenterLineCoinmunications/P¢terMoro
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:Units Lns[: i jf1T: 40 R,TAR'Hl'G,FLI.AND � VENLJE
��D�� tiat�Jf� � - -- --� . - 0�3/
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TNIS 1'T13MIT�'IAY I;F REVOKF.,D I3Y TI'IE C(TY OB SALFM IIPON Oi.ATI V O�?'"'`��I'17'S
RI.IT ES ANll REGULAT[ONS.
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STRUCNRE OWNER
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