107 HIGHLAND AVE - BUILDING INSPECTION (3) 8- 3 , 0
t The Commonwealth of Massachusetts
W
Department of t ublic Safety
Massachusetts State Building Code(780CbIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block k and Lot N for locations for which a street address is - t ava ble)
/07 za w- N,,s v o-c sA
No.and Street City/Town Zip Code O!4O Nome of Building(if lica
SECTION2:PROPOSED WORK rIrn
� gn
Edition of MA State Code,used_ If New Construction check here❑or check all that apply in the tFo rows-bcd'uw
Existing Building Repair❑ 'Alteration Addition I Demolition ❑ (Please fill out and submit ppen
Change of Use Change of Occupancy 6tber ❑ Specify: \i!tl <Are building plans and/or construction docuinenls being supplied as part of this permit application? Yes ❑ a ❑t+f
Is an Independent Structural Engineering Peer Re tew required? II Yes ❑ .No ❑N
Brief Description of Proposed Work: C O lg� ar ot C ttil CtR,' �'1Q p r
L/IrlI S elj 01 C:6tj&. flee Ato m e4lin 6 me 6Sorrrl(
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Istigation and Evaluation is enclosed(See 780 Ch1R 34) ❑nve
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. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Chuck as a licable)
A; Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5 O B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 11: High Hazard Ft-[ ❑ H-2❑ H-3 ❑ Ff-4❑. FI-5❑
1: Institutional I-1 Cl 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use[land please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
L\ ❑ IB ❑ HA ❑ IIB Cl IIIA ❑ Uf6 ❑ IV ❑ VA VB f
SECTION 7:SITE INFORMATION(refer to 780 ChIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public Check if outside Flood-Lune❑ Indicate municipal
A trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: Ur\I I
Not Applicable CI Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTfON 8:CON-TENT OF CEIt'rIFICATE OF OCCUP:\NCY
&litiun ul Coda: Use Gnmp(s):_ Type of Construction:_ Occupant Load per Hooc _
Does the building contain an Sprinkler System?: _ Special SlipuLuions:_
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1UN\T 3 e?-1y-13o5 CEN1T 1 t3 IN- I
jmtr y (3- IU -13ob 0Nts 5 5-14- 1310
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SECTION 9: PROPERTY OVVNF.R AUTIIORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/ own Zip j
Property Owner Contact Information:
Title Telephone No. (business) "Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
rName it Street Address City/Town State Zip
to act on the' ro of owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buililin is IFss than 35,0W ttI ft.of enclosed s ace and/or not under Construction Control then check here O and skip Section 10.1
10.1 Re'i'st"e'red Professional Responsible for Construction Control
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6 Name Ro'gistrmt) elephone No. e-mail address R y,gistra ton umber
Ll
Street Address zx City/Town State Zip Discipline Expirati n Date
ni C?
10.2 General Contractor
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Cutupp y Name
6c'e, A815-ov'y CS- O f-, 9 6 Z$
Name of Person Responsible for onstruction 11� -�Li�cense No. and Type if Applicable
,51 ��� e d tqg�)CA, fnA 0/f?
Street Address City/Town State Zip
-781 6 SuPJtMzfh t .
Telephone No. business Telephone No. cell a-mail ac dress
SECTION 11:VVi)RF67ZS COn1PI::N5K110,N INSURANCE AFPII?;WI1' M.C.L.c.152.§ 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 it signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) TotalConstruction Cost(from Item 6)
1. Building $ Building Permit Fee-Total Construction Cost s (Insert here
2. Electrical $ appropriate municipal factor)=
3. Plumbing $
21
it.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check t able to
payable
6."Total Cost` (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 it)this
application is true and accurate to the best of my knowledge and understanding.
Plrtse print and sign nonce Title Telephone No. Date
l✓4,,/ 12✓
Sheet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name
w�
M� Q TY OF SALEM, MASSACHUSEM
a�t,�ltci!
BUILDING DEPARTMENT
120 WASHINGTON STREET,3AD FLOOR
n f L. (978)745-9595
KINMERLEY DRISGOLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal 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:
crjc/ �
(name' of hauler)
The debris will be disposed of in:
(name of facility)
LyrI�1 r,�✓�
(address of f cility)
Signature of applicant
�Y
Date
Commonwealth of Massachusetts
x
FI q City of Salem
n ' Inspectional Services
120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
t REC_EIPT
Application For Building Permit (For Buildings other than a One- or Two-Family Dwelling)
i (Thls Sec oii for Official Use Only)! ", jF yli'l u
1
TB 14-1303,. „ � := v; .,!._' Apphed 82014/7/ f t I PIN R ill' y t,h'h=
3'' a
Building Official(Pont name) "mast '
SECTION 1 SITE LOCATION (Please Indicate Block#and Lot#for locations;for,which a street address Is not available)
107 HIGHLAND AVENUE , Salem, MA
+1 it r 9 rt if w i"" rxe-, a k{o �. ..,pu ems... L A H i(t
l �._ C"`_.... SECTION 2 PROPOSED WORK
Are Building plans and/or construction documents being supplied as part of this permit application?: No
Is an Independent Structural Engineering Peer Review Required? Yes❑ No❑
Brief Description of Proposed work: UNIT #1 BUILD OUT. SEE MASTER PERMIT #B-14-1288. PLANS ON FILE.
iSECTION 3 COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,'ADDITION ORCHANGE IN
' ., fl�
Existing Use Group USE OR OCCUPANCY(Check Here if an Existing Building Evaluation Is enclosed (see 780 CM 34))
Ii.a,.t,,.iis..t., T ,. ; r11, _.' ,,.,=wfi ..:., s Proposed Use Group:
t,=, .'„ a;
� = 4t!t =ut
-y3l, FP`a! -c 3 : 4�e
SECTION 4 BUILDING HEIGHT AND AREA, 3 , _ _. ry W' I _5t
Existing Proposed
No. of Floors/Stories (Include basement levels) &Area Per Floor (sq.ft.) 0 0.00 0 1 0.00
Total Area (sq. ft.) and Total Height (ft.) 0.00 0.00 0.00 0.00
il i �I a ;' ,a 'SECTION 5 USE GROUP 3 �{ ? a==
p ( ',�`{�(,(gyp� ��^^�-
.a,A, _.t ... .. — r peu.iu.'bt:�(}�'3 s, i.. w`d. ' n.,a 4 d,a i :nt .. d o�>-T,(,l
?$� `_' : nI mliiNkiSECT10N 6 CONSTRUCTIONITYPE n ` IN of
Prof Office
%iSECTION 7 SITE INFORMATION(refer to 780 CMR 1111 Olfor detatls,on each item)
„ t
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if inside Flood Zone ElMunicipal will not required ❑ Licensed Disposal Site
or or El
Identify Zone: Is enclosed ❑ or specify:
Railroad right-of-way: Hazards to Air Navigation: MA Historic commission Report process:
Not applicable ❑ Is Structure within airport approach area? Is their review completed?
or Constant to Build Enclosed Yes ❑ - No ❑ Yes ❑ No ❑
r l ' !:r ,I SECTIONS CONTENT OF CERTIFICATE Of OCCUPANCY as hr
f _ ,
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Edition of Code: Use Group(s)' Type of Construction:
Occupant Load per Floor Does the building contain a sprinkler system?:#Error
Special Stipulations:
an rant 'Ee i!Y'+`P"3" 'ca
Wrtt + ¢i6a ' I SECTIONS PROPERTY OWNER AUTHORIZATIONIrr
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IS,N�Te" `PERMIT:aet
Commonwealth of Massachusetts
'I G City of Salem
n Inspectional Services
r ECEIP T L v 120 Washington St,3rd Floor Salem,MA O1970 Phone:(978)745-9595 x5641
R
ROIKE PROPERTIES,LLC 39 MAIN STREET SAUGUS MA 01906
(781) 760-1140
If applicable,the property owner hereby authorizes
Supreme Builders 58 Glad Valley Drive BILLERICA MA 01821
To act on the property owner's behalf,in all matters relative to the work authorized by this building permit application.
'. SECTION 10'CONSTRUCTION CONTROL Please fill out A endix 2 °` ,rI `"'
( Pp )� p. - _
1fulpr� , '(If buildingis less than 35 000 cu.ft;'of enclosed space and/or riot under Consfrucbon Control then skip Section 10.1
i� 00 1'Registered Professional Res onsible for Constructor Controliu
Name Phone Email Registration Number
Address Discipline Expiration
Date
10 2 General Contractor ��,craws
R,ry^vs,I�.... '3.�,.,..:� n,,, „R as.�w"1�I t;YHNr , u y. ,�i' s�,.� „r,� v.
...... .,,3:...by lINHs,,exm� ,... s5a r..:..... u
Company Name 69628 General Contractor
Supreme Builders License no. and License Type if Applicable
Name of Person Responsible for Construction
Address: 58 Glad Valley Drive BILLERICA MA 01821
Phone (781) 953-6036 Email Address
SECTION 11 WORKERS COMPENSATION INSURANCE AFFIDAVIT(M G L'c 152 �tu„'
s:,..,. i
KH
A Worker's 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 signed Affidavit submitted with this application?
ra
" ' 1 "dnFs7mtSECTION 12 CONSTRUCTION COST AND PERMIT FEE� �pU.WNIL
� " #f
Total Estimated Costs(Labor and Materials): $0.00 Building Permit Fee: $0.00
Enclose check payable to the City of Salem, Ck#
" tm7:x SEGTION 13 SIGNATURE OF BUILDING PERMIT APPLICANT e n
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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.
(781) 953-6036
Please print and sign name Title Telephone
Address: 58 Glad Valley Drive BILLERICA MA 01821 Date: 8/7/2014
Municipa61l Inspector to fill out this section upon application approvalI,(}'� t,'.„ 9 � � I1 d,"8/7/2014
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