0055 HIGHLAND AVENUE - BPA-14-1880 kU
The Commonwealth of Massachuset sCTIONAL SERYI E ,
� Department of Public Safety
9/ rMassachusetts SGue Building Code(780 CNIR) Z014 DEC -4 P 4: 0 +
� building Permit Application for any Building other than aOne-or Two-Family DvJelling
(This Section For Official Use Onl )
Building Permit Number: Date Applied: Building Official:
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 :5 Niq Ir^nck 441L Sr,\n nn O\ri--(S 41it 1�\I
nd No.a reef City/Town Zip Code `iV ime of Building(if applicable)
SECTION 2: PROPOSED WORK
Edition of MA State Code used S— If New Construction check here❑or check all that apply in the thvo rows below
l Existing Building 0 1 Repair❑ 1 Alteration PI I Addition Cl I Demolition O (Please fill out and submit Appendix 1)
t� Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes fl No ❑
Is an Independent Structu ml Engineering Peer Review required? Yes ❑ No Ia
Brief Description of Proposed Work: Aina an O-�C:�-a- Gvsc) 0_,44Miats. `�1r2. Cexrr'td Of'
-\ca k- an I .
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 3h) ❑
Existing Use Group(s): Proposed Use Group(s): R,. &wAs
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Pei Floor(sq. ft.) T{Dos 400S (''r
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Asseurbly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4 Cl A-5 Cl 1 B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ FL• 11,1h hazard II-I❑ H-2❑ FI-3 ❑ 1-1-4❑ 1-1-5❑
1: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ RA❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION G:CONSTRUCr[ON TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB [ IlL\ ❑ IIIB ❑ IV ❑ VA VB ❑
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:
Public Cl Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site Cl
Private❑ or indentify Zone: or on site system CIrequired O or trench or specify:permit is enclosed ❑
Railroad right-of-way: hazards to Air Navigation: \i Ili t rit C. m 'i rein R.. . (rill:
Not Applicable CI Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ I Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): _ Fype of Construction: . Occupant Load per Floor:.
Does the building,contain an Sprinkler System?: . Special Stipulations: .
611 I= {-4PW k5 2 SA�--T s a r p c, s
12- 18 �� y r, .v
r
SECTION 91 PROPERTY OWNER AU'rifORfZATION
Name.and Address of Property Owner f
•No�l�,-5�.�,-c lti.e��cA1-'r(��ic-f $I N;�h1w-d 14v� Sw rv�
Name(Print) No. and Street City/Town Zip
C#Property Owner,Cbntnct'rnformation:
Roloork P I% a�4- ASIA 50��foa-30a _ (gyp-Y, J -
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes .
Name Street Address City/Town State Zip
to act on the property owner's behalf, mail matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
FA rj —141,dr4 7$- a�S`7 S �S'iN� f�� •cS.
Name(Registrant) Telephone No. e-mail address egfstraliun Number
Street Address City/'rown State Zip Discipline Expiration Date
10.2 General Contractors 1 - `
`
b I.ar.far Gh
. . lASLLGTIQn ,-r
Company Name
Vlqnfek i oaa Ls -oF1 `id1
Name of Person Responsible for Construction License No. and Type if Applicable
Q &rcAan ?Q3l K:Shue, i--�\A o3o(e �
Street Address City/Town State Zip
cam, -S58- �Sla3Gus-�S l,o & kDNC �1 r�av,cc . nA
Telephone No. business Telephone No. cell a-mail address
SECTION 11: WORKERS'COMIPI NSA I iON INSURANCE Ai°YIUAVI I M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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? YellNo ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total construction cost(from Item 6)_$ -4. d_
1. Building $ 60 .00 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical S 60,0 0 appropriate municipal factor)_$
3. Plumbing
.1. Mechanical 04*A-C) Sprhur $ a UOupW Note: Nlininuun fee=$ (contact municipality)
5. Mechanical Other $ '75-0 00 Enclose check payable to
6.Total Cost $ f7 O 1 (contact 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 of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
N t"ea dosw4 G-ua-5-i&-81 A 3 0
Please print and sign name , ` Telephone No. Date
of (s rake . 1 L�.Ww i-)� 636 fe �.
Street Address City/Town tine
Municipal Inspector to fill out this section upon appli pproval:
ame
T° CITY OF SALEN1, lL-kss,ICHUSETTS
BUMDING DEP.,,RTNff-NT
120 W.1SHLNc;TON STREET, 3'a FLOOR
TEL (978) 745-9595 4
FAx(978) 740-9846 �
KI\tBERiEY DRISCOLL
rLbL1YOR THobw ST.PtERRs
' DIRECTOR OF PUBLIC PROPERTY/BCILDmIG CO\LQlSS[O.NER
Workers' Compensation Insurance Afrdavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
NainC lHusin¢ss.Organiratiarvindividual): k•D .tJata,--n - Con-.A,rah 6rl Ula
Address: cl (e"(-01\e .
City/State/Zip: Ah2U /030 G-A Phone H: b0S- S`i 8- FS1 a3
F2.
c you un employer.'Check the appropriate box: Type of project(required):
lI am a employer with 4• P9I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-lime).• have hired the sub-contractors 1 ran a sole proprietor or partner- listed on the attached sheet. I 7. Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'ctsmp.insurance. 9. 0 Building additiun
(No workers camp. insurance - 3. 0 We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 I ran a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'Bump. C. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.1 t employees. (No workers'
Gump. insurancerequircd.j 13.❑Other
•Any uppliu:un tlwt chucks box 01 maul ilia rill our the section below showing their workers'eumpensatlun policy intbrmattun.
'I lomeawtwrs wha.,uhmit this ailhinvil indicting they am doing all work and then him ounido contractors mail mibmil a new JMdavit indicating such.
mawm thul cheep this box mm1 anachod in addi,iutul shut showing the mane of the sub4entnctots and their workers'comp.pulley inlomtation.
l am un eutpluyer that is pruvidlnK lvarkers'conipeasailon husuralrcefor my empluyees. Below/s due policy and fob slid
information.
Insurance Company Name: ON -------
Policy it or Self-itn. Lie. 0: Expiration Date:
Job Site Adtkess: SS- 41 n>,lard Ave_. City/Stale/zip:�xlgyyv / P'l c.�°)— 6
Attach a copy of the workers'compensalloo pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL e. 132 can lead to the imposition of criminal penalties of a
line up to SI.500.00 und/or one-year imprisanmcnt,as well as civil penalties in the form of a STOP WORK ORDER and aline
orup to S250.00 a day against the violator. fie advised that a copy of this snatement may be rurwirdcd to the Office or
Invesligwions of d,c MA for insurance coverage verification. -
l du hereby certify ttadrr Nm pains sad peaoldes of perjury that the hifurnmllmt provided ubuve is true and correct
Si•.n mar "I&., _ Date: J 3/ W'4
Phoned: (o0.�'SSfc—£$1
c
!Jf/irist we mJy. no not write in this area, to be completed by city ur lawn n/JleiuL
City nr l'usvn: _ _ Ncrmitfl.lcensc q__.
Lssuing.l ulhurity (circle one):
I. Ifuard ul Ilealth Z. I)uildlnq Uepartntout 1.Cilylfnwn Clerk �. Electrical Inspector 5. Plimubing Iu.tpector
6. Other
I
Conlad Perim): ______ Phone .7:
CITY OF SALEM, MASSACHUSEM
3 j BUILDING DEPARTMENT
120 WASHNGTON STREET,3m FLOOR
TEL. (978) 745-9595
F
KIMBERLEY DRISOOLL FAX(978) 740-9846
MAYOR TY30"STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONaUSSIONER
Construction Debris Disposai Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
AN�ed l,3cs�
(name of hauler)
The debris will be disposed of in:
40SRA-A.I
(name of facility)
(address of facility)
Signature of applicant
Date