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0055 HIGHLAND AVENUE - BPA-11-726 � J 1 n ' � ; ; Y The Commonwealth of Massachusetts �- i.`.'j y � Departmenf of Public Sa(ety '� I ����� ,j \la...iihu.i91.til.�tr Uwl.lin�;C���dr I�90 C\Ilil ti.•��.nih E.iiu��n ! City o(Salem � 8uildin Permit A lication (or �n Buildin ofher lhan a 1- or 2-Famil Dwellin � ��hi.�rcuun Fur�)flic�al U<r Unlvl � IiuJdm�;Prnnil Vumbrc Dair ApF�Grd: G! !� Bwl.ling Inxprctuc � SECTION 1: LOCAiION IPle��e indiott Black I and Lot� for localion� for which � sfnet addr<s� is nol�v+ilablel � �Aqqq�, �p SS N�u+l�o,.h A�� Skl�..� M�- ory�o ,�iU-�/�kA <f.�</ j YI{, \��. and titrrel l il�' /T.nvn Lip Cude Namr ul Budding Pt.ippin.iblrl � II\ SECTION 2:PROPOSED WORK li Nrw C�m.tructiun iheck hrrc O��r thrck all�hal apply m Ihr two ruws brluw ._..----��-Esrting-BuiWinh�---RrF�air-� -Altrraliun$--Ad�Hien-C� rtwliliun-0-l�Rkax-fill-uuFanii-subm�o-.�}��radix Chingr�(U�e ❑ Changr o((Xcupancy ❑ lJthrr O Sprnfy� Arc bu8ding pl.�ne,ind/ur curutructiun documrntsbeing wpplird as p.vt of Ihis prrmit applicatiun? Ye. k7 Nu ❑ Is an IndrprndrN StrucWral Enginrrring Prrt Rrvirw rryuirrd? � Yrs ❑ N�� ❑ � Dncf De>cnpliun of Prup�>.�d Wurk: L�eMt� S •�i"2� �� �:c�AllS� CDe/ST�cvcT$cv<.�.N-I w�Us u'fi51'T.�T'� ' �"2L � � SECTION 3:COMPLETE THIS SECiION IF FJ(ISTINC BUILDING UNDEAGOING RENOVATION,ADDITION,OR CHANCE IN USE OR OCCUPANCY Check hrre i(an ExbHng Building EvaluaHon is enclosed(See 780 CMR 3402.0) ❑ � Eaisting Use Group(e): � / Proposed Use Croup(>): i' Existing Havard Index 780CMR.J4: Proposed Haznrd Index 780 CMR 34: SECTiON 4:BUILDING HEICHT AND AREA - . _ Facisting Propaxd No.af Fliwrs/Storiev(intludr basemrnt Irvels)&Area Per Flaor(sq.ft.) ToWI Area(x�.ft.)and TuWI Heighl(ft.) . SECIION S:USE GAOUP ICheck a�a licablel A: Aaeembly A-1 O A-2r ❑ A-2nc O A-3 ❑ A-0❑ A-5❑ B: Busineas O E: Eduutional ❑ F: Pacto F-1 O F2❑ H: Hi Hazard H-1 ❑ H•2❑ H-3 ❑ H-4 O H-5❑ 1: Institutional I-I ❑ 1-2 ❑ 1-1 O I-�❑ M: Mercanlile❑ R: Realdential R-1❑ R-2 ❑ R-7❑ R-� O � S: Srongt SI ❑ 5-1 ❑ U: Utility O Special Use O.ind Irax descnbe brluw: SF,rctal l.'�r: ' � SECTION 6:CONSTRUC7tON TYPE lCheck a a licable) � � IA ❑ IB O IIA ❑ IB 9 � IIIA ❑ IIIB ❑ IV p . VA p vB ❑ � SECTION 7:SITE INFORMATION (nfer to 780 CNR i i lA for det�ib an uch iteml � � frmch PartniF. � Urbrie Ii<�nov�I: - . � i W+1<r Supply: Flood Zone Information: Sewagr Di�pasal: I Pubhr�- ChciG�hntl.idv 19�.�.1 L��nr❑ InJ�t.ilr miminF•al� Alrrnch wdl n�tl he Liirmed Lh.�n�..il�ile ❑ ❑ ��rindcnblcL�mr: ��n�n.�tr�cyrm❑ rcyuircJOur�rcii.h ��� .�,ccdc. � Ih'ic.ttc _ � �•rrmil �.enclu.eal � _ _-- . i It�ilm�d righl�u/�way: Har�rds fo Air Vavig�lian: �I�� I b.i,..n � ..����n�..�,.,,R.,�� „ ;�,., I � '\��1 \p�di..�l�1��0 I,�Iru:l�nc�.�d�in.nr����rl.i����u�.idi.�n•.�' I.Ihurtic�ic.� :,.in�.I.IrJ ..—�I . .�� 1�.., ".nln� HuJJ.�nJi�...l � � lc.O �•t.\��❑ la�. ❑ \�� ❑ � tiECiIUN A:COti fEVT OF CERTIFIC.1 fE UF UCCCP.\NCY __� I .h)n�n �,Il ..Jv . .__ L�cl.i��u��i.l __ ����r.ql-��n.Iru.U��n '_'_ I�ri�iF�.infl ��.�J ��crIL���i � ._ ___.. . __.. � IL.�-ih.�l•�ul,Irnq,,,nt.un.in�pnnAlcr?�.Icm` . >peri.d�li��uleliun. � � .�� Gr/y/l�i^ e�S/Vvw � �• 'W1�7 �/^ / -�/� �� `� � ��/���,,P� !` 1 /° I/ � �, SECTION 9: '':°ROPER7'Y OWNER AUTHORIZATION . I \'.�mi•.niJ \dJn•a.ul Pru�.crlr l)��'�irr /�s `x L g l N�c-N l��x A�r _S'�-l�•n �s� o i9>e _ --- ; \.�mr ll4in11 N��.and tilrcrl 11h� (�nvn ' . [�F' I I'n�F��•rlrlh.nerl�,�nl.�.11nturmaliun: - �nN �s�As(��i P,cor«rnu.e- 9��.�5 . zS93 781-9/3 . 234�F �idr �rlrphunr Nu. Ibu..ina:.) irlr�•hunr Nu. lirll) r-m.ul.�,IJrr., I If.����•h�.iblr. Ihr F�ruprrh'���.ner hrrcb��.iuihun[r� � Vemr � �trortAJdrr�+ lih�/iu�vn � til.��r l.iF. in:�ct un ihr .n�•vrh� ,n.nrr�.brh.Jf, m ell maltrrc rrlaucr ni �vurk .�u�li��ritrd Lv thi.bu�lil�n • �rrmrt.i , �hrauun. - . SECTION 10:CONSTftUCT10N CONTROL IPlease (iil out Appendix 2) � 111 bud.lin•is���+iFun Ji.lhlU:u.ft.d rnduvJ+r�ie.inJ/ot nul unJer Grn>trurli��n Cunlml Ihrn chs�k hrre O and.A� +\vb�m 111 II 10.� Re islered Pro(e�sianal Rrs onaible !or Conetruction Control � C� :T�kD.��' ti�+rirtt7 r rp une u. r-m.0 a rrvs eglstr,iUun Numbrr � f3 / /fi�ff�%Mb lq�Ci 9?�f.35� 5trrrt Addrose . . City/Tuwn titatr Lip Dixiplinr - Eapir.iuun 0.rtr ]0.2 Genenl Confractof � � .cc;an�v „� Co,t.r� C�>m any Name: • � pP�-�� �7,�u,q,�� U��'(�9 `-� �?��//zn� N,imr uf Prr.un Rr.<Fx�n.ibir fot Cunvtructiun L�crnx No. and Type i(Applicable .33 Rlv�av«..� AvG Street Address City/Town � State � Zi � P Telr hone Nu.(business) Tele hone No.(cell) � e-mail address � SECTiON I1: WORKERS'COWII'ENSATION PISURANCE AFFIDAVTf(M.C.L.e. 152. 25C(6)) A Wurkrrs'Cumprnn.tion Insurence A((idavit from the MA Department of Industrial Accidents must�br completed and � +ubmitted with this application. Failure to providr this affidavit wi11 result in the denial of the issuance of thr building permit. � Is a ei ned A(fidavit submitted with this a lication7 � Yes O Na O � SECT[ON 12:CONSTRUCfION COSTS AND PERMiT FEE � � Item Estimated Covts:(Labar . - . and Materials) Total Construction Cust(from Item 6) =5 I. Building b ���0 Buildin Permit Fee=Tolal Cunstruction Cost x 2. Electrical 5 x _(Insrrt hrre DO� appropriate municipal facror)=S 3. Plumbing § �J - � � J. 1�Irchanical (HVAC) E Note:Minimum fee=�f (contact municipaliiy) S. Mechanical 1�7thrrl 5 � Enclosr chrck pay.�ble to - 6. T�rtal Co.t � � f ��� � . (contact munici alit )and write chrck number herr ' . SECTION 13:SICNA7'URE OF BUILDINC PERMIT APPUCANT . H��rmrnnti my n.nnv beluw, I hrrcby.i�tent under Ihr p.unsand penalNr.��f prqury th.�t all u!thr mlurmati�.m n�nt�imrd in hi. I .ipplic.�h��n i.lrurand.ucuratr�tn thr id mv knu�aled�;eand unJrr.l.�ndin�;. _J��S �IA/GG.�9�//)�2GS..���� , �'__—.__ J�Q(��j� ! � I19a.�.cpnm .in.l .�pnn.im� fillr .;/ L���� ��(// � Gdi� i c \�� U.nv � — �In�cl 1,1.� �.. 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