0055 HIGHLAND AVENUE - BPA-14-1537) i •
s3-7 t (ciy 418c
;► ' The Commonwealth of Massachusetts
Department of Public Safety
a„ \lax.lchusvlis State BUdatingCodw 1:80 Ci\tFIL�Y�Wrrt.UL$ERVECES..
City of Salem fIJYt FIN
Building Permit Application for any Buildin other than a I.at Z-Family Dwellinjill
1 This Section For Official Uwe Only) 4
Building Permit Number: D.lteApplied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not available)
Xu.and Sweet CRY /Town Lip Code I lme of Budding(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in thr two ruws below
Existing Building W Repair❑ 1 Alteration q Addition O Demolition O (Please fill out and submit Appendix 1)
Change of Use O 1 ChangeufOccupancy O Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes 91 No O
Is an Independent Structural Engineering Peer Review required? Yes ❑- No fig
Brief Ck-wription of Proposed Work! Alae.r•na nn ex.S\:no Aral 1n�. fooYh �o cfr�mnrle.�-e_
I
51.� ..or- tJ¢iJ ACV In 3 rri6 ns
I
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADOMON,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing UseGroup(s): ( Cal Proposed UseGroup(s): , n.r--SS
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.It.). $9 (0 1 5f9 (P
Total Area(.sq.ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicabla)
A: Assembly AA O A-2r O A-2nc O A-3 O A4 O A-5 0 1 B: Business §1 E: Educational O
F: Facto F-1 ❑ F2 O H: High Hazard H-1 O H-2 O H-3 O H-4 Cl H-5 O
1: Institutional I-1 O 1-2 O 1-3 O 14 Oi M: Mercantile O R: Residential R-:O R-2(3 R-3❑ R4❑
S: Storage S•I O S-2 O U: Utility O T Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O Ill O IIA O fill )Q IIIA O 1118 O IV 13 VA O VB O
SECTION ?:SITE INFORMATION(refer to 780 CMR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: LLjcvn�wd
s Removal:
Put+hc O C'hcck d uuUldv FIuuJ Lunn O Indicate municipal O A trench will not beDispu.d Site OIancale❑ ur mdunuAv Lune: or on.Ile.cdvm❑ required Our trench :
permil I,vnclo ed ❑
Railroad right-of-way: Huuds to Air.Navigation: xL\ I Il.bnr l Innu.•Iun lt•+uv l'nv r+
\ul \pplic.lNeo I.�1nlclun•+cllhul.urpurt.I)+pn-achmra' - 1.their rvuv:cannpletc.dI
r G nt.clit uI Buda(voc61rd O 1 v.O or.\u❑ Ye.❑ \u O
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I .IItlun.a GO,- L,v ra i+a•ul lLndnlclu•n: Occupant Load per l lemur
16w.III,-building cunlam.ul Sprinkler m,tvm' �ivclal�h)+ulollunv .
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Namlp avd alddrv..ao ProlperN•Owner 1�
aypm Untn,-�a�_ \ , 1 SQl.11�ry� d\nl9G
.Name(Pnnt)j +rr...,.., .Vo..,nd Street Cit)'/town Lip
Pnp vertu lhv nrr�(;tinl act Inform iI
�� +�.IV terra :.,Informq.
�ZC,.
of
Titlen w m /+ ea t17A dlA� relrphonvl.No. (bu.nr..) reiephvme No. (cell) a-mad addrk�. .J
If ap),hGablr, the pnpperttwnvner hereby authorizes
.Name Strive Address Cily/Town tittle Lip
to act on the pro+vrl% imner'.behalf, m all matters relalirce lu work aulhonzed by this buldin• permit a + pitcatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buihtin is Ices than 35,000 cu.It.of vndus rl> acv and/urnot under Cominiction Contntl then check hen Cland,lup Smiwn 10.11
10.1 Reitistersid Professional Responsible for Construction Control
C•L, s 97Y-3SH. �s9s tTEr�c]k4�_nGc1 �s.o
Name(Registrant)"' Telephone No. e-mail address egistratiun Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor '
kab a
Company Name:
Dr�ntelC_S -Dts19O 1
Name of Person Respimsible fur Construction License No. and Type if Applicable
`nl W W 030 to d-
Street Address City/Town Stip
(4&-55� 3 8)a .�- Wt a- kDtaC.@ C-0"Y"saate t+, n�Zk
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERSCOWENSATMN INSURANCE AFFIDAVIT(M.G.L.c.152 1 25C(6))
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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=f 3 CJ 0 O . 0 U
1. Building f ' U U Building Permit Fee-Total Construction Cost x_(Insert here
12. Electrical f '5- 000,Do appropriate municipal factor) f
3. Plumbing f 1.01J0. 00
4. Mechanical (HVAC) f Note:Minimum fee•f (contact municipality)
000, ov
5. Mechanical (Other) f Enclose check payable to
b. Total Cost f 0 06 , /]O (contact munici alit )and write check number here
SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT
ley vntvng y name below, I hereby altest under the pains and penalties of perjury that all of the information omt.uned in this
.lirylu n
icao``n ims true and accurate to the be.l of mmy knowledge and understanding,
Xh es--- 4,n 1 1
19eaw prim and ign name fit fclophone.No. Date
tJa-')vuo— o3O b.L.
Vry• Citsi Town St.lte Lip
1lunicipa nspector to fill out this section upon application approval: 0 /b!N
Name
t
CITY OF SALEM
PUBLIC PROPRERTY
y/ DEPARTMENT
1
1.11: M111 ' • 11
\I •1•'M 'I:C�{�H NCI.•.pq)1/!rr •}111 fl,�I.1N 11111 d 1 ..I'r .
- I rl:v:M%14•!4N �F Cf:'!//•:JJ'IrM
Con struction Debris Disposal ACOdavit
(rtiyuired lur III demuliliun:ud renovation work)
in rccunlatcc with the siult edition of the State Duildin`Code, 790 CMR section l l l.s
Debris, and the provisions ul MGL c 40,S 54;
Ouildinli Permit N _ • _ is issued with the condition that the debris rpultinl{ ftom
this work shall be disposed of in a properly licensed wa+te disposal fbcility as defined by MGL c
111. S 150A.
The debris will be transported by:
�\lieol W� l-e-
• l luau ut'luuler)
The debris will be disposed of in
(nyrltlrI a►1Illy
l;I,ldrsrful'I'xdily! �
aaaawe of Iwrnlil JpylhalM
�1 FfI �
Sale
CITY OF S.ULE.ti(9 AASSACHUSEM
a� 9L'Q.DCiG D!).�RT�d�iT
• 1_O 1V.\3HCVGTON STIIERT. )'�FLOOR
Mw (978) 745-9599
'a F.%X(971q 7i49&"
KJ}®EJUAV DRISCOLL
:NAYO� I1w1w�p ST.PaRRs
DIRWM&0F1LaLXrROpERTT/Kl DLvIcCO�ansSlONeR
Workers' Compensallon Insurance AMdarils Ouildas/ContrsctorWEleet►(clantllPlumbers
>unlleant Infnrmallo Mon Pr(nt Ledbbl
volne ltluntte+naraaetratfen ltwkvdtrrll� � � l�]t�'c l�n<4n �l ova �L
Address:
Cily/StaldZip: <1.. A- Ayyjo3g(-a i'bonoM. (n03-S(s - 81a3
Are yom u employer!Cbeek Ike appreprlaM Type o/plojtld(►egrl►Mt
1.❑ 1311116.rnPlsyes With a, 1 am s Friend eonsractse Well 1 R (]Ner caasarfiretien
.mPlayeo(AA answer pmt-tfato].e have hkad 1M au►emttraemn
1.❑ 1318 a wide prepriasw'W partner. listed an the attached sheet= 7. ®Rentmkling
.hip and have no amployaes Thews su►commsmn he" LC3 Oomoiirims
Working fame its any capacity. Wallow comp.insmaasa 9••Q QtriWing adowoe
INa Wakes'coop.inwnnce J. ❑ We an capsrMlarr aced in
ollkms haw atsrdaed thrl► 10.13 Electrical repair or additions
1.❑ 1 am a hhonmw rw doing ad work '1(,��wPar 1W� I I.Q Mundsi s repairs or add ides"
myself(Yo Workers'canµ 12.0 Rasf repairs
insurance roquiredj It c"ham'(NG"'Ocritars' 13.0 oche
canµ instructs regrimd.j
•n■y aprlleew iti d WO bm/t awd AW Ile ur thr ueter ba c e osawtea sir v>~MMMUttm pMay laaaafifiifia.
11 6wwraww who rubles the ararvY indicating the/ore Jain fill wUk and it Use auribtaoaanauw ors adnb a.a r b.0 wdkeiae ref
1p+etwnar dtr 1111111111616 big and agewW r aJatlerl abr dwly ew aaeaa e/Aa et►{ertaraa a"'bob wwaes'ramp totter iae nwlso.
/stttsw/w/1gwrArb�rsrl/bynwR/ra'rawpwndea/wrwrwa/LrgayAr�wa QtMrbrAr/sHeTaw/�iWr
ie/irnrrda�
In.urance Company.Name:
Vnlicy a us Self•ins.Lie.se Expiracies Dace:
lub%if Adds; Ciry/StatarZipr
.\clack a copy of the Wertan'compommon polky dmknti o pap(A 1 9 rbe Palley number sad seplresko drej.
Failure to aecwt covorsp=required undrr Section IJA of MOL R 152 case lead to the impositkn of criminal penalties of s
- - fine up to S 1,500.00 accuse once-yew imprisennwne,as well an civil penalties in the farce of a STOP WORK ORDER and a line
Of topic S230.00 a day twines the violator. fie adviaad thus cupy of this,astmwnd may be rurwrdad to the OrlTcs of
I ncc.0 tialiuca of ire nlA for insurance cov.rotio vwilkatioa
/JI hereby
cecertify umJdw IAa 'q awd y/wr/IM aI//r/rq rAar rAa in�arwardM/rewlrl u11q it mrI Yw1{•rrrld
lytq; 'A41 $! an iol
Onf{"I oI Yl/YnI�1 /Ye move NI/M is$/AY Y/oa4 to be 4v#w#*1d Jj city or tlane n//Arid
City or fuwn: PrrmfN.leenrt/ i
hwtn�.\uthordyitircle #AQ:
i Iluard of Wallis 1. Huddlatl I/eparimvnt 1. Citytrowo citrk 1. Electrical Inspector 1. Plumbing Impostor
6. Other _
l.•"ntacl Pcnon: _ _ .. Phone a.