0114 REAR HIGHLAND AVENUE - BPA-10-588 ,► The Commonwealth of Massachusetts
• I, Department of Public Safety
.\Llssachuset is State Building Code(780 C\IR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I-or 2-Family DWelliadl�-//
(This Section For Official Use Only)
Building Permit Number: Date Applied: d Building Inspector:
SECT N l: LOCATION (Please in irate Block M and Lot N for locations for which a street address is not ays able)
( i
No. and Street 14 Citv /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ Alteration ❑' 1 Addition❑ Drmulition ❑ (Please fill out and submit Appendix 1) '4;
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or cunstructiun documents being supplied as part of this permit application? Yes ❑ No E)--
Is an Independent Structural Engineering Peer Review required? Yes ❑ No la'
Brief Description of Proposed Work:
r o /- v ih o P/�. ✓} rrh �h � �
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
"'"Q^a"•+"` "Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile R: Residential R•1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Dispod
Trench Permit: Debris Removal:
PP y'
Public ❑ Check if outside Flood Zone❑ Indicate municiA trench will nut be Licensed Disposal Site❑I'rica to❑ .r mdentifv Zunr: nron site warrequired ❑or trench or.peclf%.
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: �I:� I ea„ri;t", nnni..i, „K.•l;,•,t Pn r;..:
\ot ApldicA,le❑ I,Structure lnlhm airport approadt area I.,their re\ v%\ ounpleted'
n'(•,nt�cnl to Budd rnio.cd ❑ 1'c.❑ or No❑ 1'rn❑ ..\u ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
lidition of Code: U,e Gr,nipl�i: fc e o {" ( 1(.unplrUitll m: OrQiprint lU.h pc'r I'IouC
Uoe. Ihr budding;contain an Sprinkler s,\ Iem': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
A.r-Thm/+ + fa—A" laf�'Ii'a�S- II`Ia H.- 4LL Awe Ixle�. YWa al5 ?�
Name(Print) I No.andStreet City/Town Zip
Property Owner Contact Information:
Tenn/ Can..vel1 )9br.;nlrir.r��J p1$- �YJ_371�
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the properly owner hereby authorizes
Name Street Address Citv/ own State Zip
to act on the aru pert%owners behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 350)0 cu.Rut enclos. si s pace and/or not under Construction Control then check here D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
t Name(Registrant) Telephone No. . e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
S-c en /r l�S ,c
C. p r N`am�jt SLt'it-S C S- L
�iPnJe c. tl.)G/1�/r
Name of Person Responsible for Construction License No. and Type if Applicable
I 'On %rvr- 1ra� a I� a--t
Street Addre City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail addre
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes C9—No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=$ I 1 k3 v
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 1-1 ri k o (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 th)best of my knowledgeand understanding.
re�f,• Q!ZJ S3 (_ 166 3 3' -I o
I'lease print, nd sign n,ome ritle Telephone No. Dale
^S R ✓A�tl t al V) UIT 6
titreet Address Cit%i own SL to Zip
Municipal Inspector to fill out this section upon application approval: -J'�—�—
1''
ASPEROO-01 CACI
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD,YYYY)
TM 1/a/zo10
PRODUCER (508) 852-8500 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Protector Group Ins.Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
100 Front Street, Suite 800 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Worcester, MA 01608-1435
INSURERS AFFORDING COVERAGE NAIC#
INSURED Aspen Roofing Services, Inc. INSURERA:Acadia Insurance
58 R Pulaski Street INSURER B'.Ace Property&Casualty Insurance Cc
Peabody, MA 01960 INSURER C'.
INSURER D'.
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR OD'L POLICY NUMBER ` POIJCYEFFECTIVE POLICY EXPIRATION DATE MM/DD/YY) DATE(MMIDDIYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIAL GENERAL LIABILITY CPA520233366 12/31/2009 12/31/2010 DAMAGE 10 DIEPREMISES(Ea oNcurreence) S 250,00
CLAIMS MADE FX1 OCCUR VIED EXP(Any one person) $ 5,00
PERSONAL&AOV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOPAGG $ 2,000,00
POLICY rX PRO LED
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
A ANY AUTO MAA520236243 12/31/2009 12/31/2010 (Ea accidenq
ALL OWNED AUTOS - - BODILY INJURY
X SCHEDULED AUTOS (Per person) $
X HIRED AUTOS
BODILY INJURY $
X NON OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY'. AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 2,000,00
A X OCCUR ❑CLAIMSMADE CUA520236246 12/31/2009 12/31/2010 AGGREGATE $ 2.000,0D
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X WC STATU- OTH-
T RY LIMITS ER
B EMPLOYERS LIABILITY NWC C45847962 12/31/2009 12/31/2010 E.L.EACH ACCIDENT $ 1,000,00
ANY PROPRIETORIPARTNERIEXECUTIVE
OFPCERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S 1,000,00
II yes.describe untler 1,000,00
SPECIAL PROVISIONS below E.L.DISEASE POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Aspen Roofing Services, Inc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
58 R Pulaski Street
Peabody, MA 01960- NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) 0 ACORD CORPORATION 1988
CITY OF S.�I.E.`I, NlakSSACHL;SETTS
BUE DLNG DEPARTMENT
120 WASHINGTON ST&EET, 3"a FLooit
TEL (978) 743.9S95
F.ut(978) 7449&W
KIJ[BfREY DRISCOLL
MAYORTtohW ST.PmAn
DiRECToti OP PL BLIC PROPERTY/gC01DLVG CONLNUSSIONER
Workers' Compensation Insurance AMillsvit: Builders/Contractors/ElectrlclansiPlumbers
anolle2nt Information Please Print Legibly
Valle leuairrc>,aOrynuatiocr ln,Lrcdual): !/s��n ��' � h JGr✓.�*," Yn"c ,
Address: S� ti /'v(n rl r
City/StatdZip: 144 li-,- Y"11- J I'i 6u
,ttreeyyou as employer'Check the appropriate box: Type of project(required):
1.L4 1 am a employer with 4• [1 1 am a trneal contractor and I 6. New constructiao
cmployces(full and/or pan-tim a
e).• have hired the su&cra a cco
2.❑ 1 am a sale proprietor or partner- listed on the amiched sheet: 7• ❑Remodeling
ship and have no employees Thera sub-eommmu ee have I. Demolition
working for me in any capacity. workers'comp.imureaot: 9. O Building addition
INo warken'comp insurance S. ❑ We am a corporation and it. 10.0 Electrical regain err additions
odkm have exercised their
1.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,91(41 and we have no 12.caloof repsirs
insurance required.1► employees.(No worksa' 13.0 Other
comp insurance require&)
•Any applicam it dw ha boa et mewl air too oax the mlioi btlaw sbowiy thdr warkm'rurnpna dun policy infwntaloa
'I I.wrurAa rho su6awl this aMdsvir indicates they are doing all work and toes hiker etraids can rtreclwa men ahmb a new Mdavit indkai,y reek
4%mtlinon del cheek this box mug agashsd ere addiliwal dog sheaving dw rem•of dta ark4yolmawm and thtk wohwa'ewes,policy farwmoom
l oar aw tarp/oyer that b providing workers'cowpirmadea lnsarsaafw cry tarploytex Odom fa the polty sad/sd st r
infornradork n' �
Insurance Company Name: rsc� Pry a,4 + CA s-g 1 :3;I—e—
Policy N ur Se*ins.Lie.N., C LIA J d, 0 3 6 " 6 U Expiation Date: I d t" t
Job Site Adckcrs: 114 4 City/Statd2 ip: S9 tQ'M C✓19 7
,%rack a copy of the workers'coffmPfmsstiOm poUey dgeisntlos psp(showing the policy Numbers d expirathn date)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofs
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a flee
Of up ter S250.00 a Jay against the violator. lie adviAW that a copy of this statement maybe forwarded to the OtTice of
Invc,ttgmione ul'dsa MA for insurance coverage veritieation.
/de hereby crrrij uudtr the paiws and ptnebtles of parJury that the inforwatloa provided above it ova and correct
Date: 3 11- l a
Phu is 5— t_ 2662,
D/ffrial uat only. Dona write is this area,re be,ampleW by city or rown n/Jlaval
City or fawn: Permit/I.IccnseM__.
i
hsuing Authurily (circle une):
1. ❑uard of Iltallh 2. Ruihling Department J.City/town Clerk 4. Electrical lnspcoor 5. Pl71nipector
6.Other _
LunlaclPerson. _ ._ ._ Phone#:
CITY OF SALEM
S PUBLIC PROPRERTY
J.i
DEPARTMENT
I'.1„µ I�Q\Y'.�il ll.\b: !V$rNll r ��•11 f fl,St.\%i.\I 111 it I -
M:97t•74+9395 •F.\3:978.7410.9441
Construction Debris Disposal Af idavit
(required fur all demolition mid renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q _ _ is issued with the condition that the debris resulting from
this work shall he disposed of in a property licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Dw I I (nameoChaum,
J The debris will be disposed of in
Qlame acllty)
ern�Lvl�w nra-.
(addre+s of 1'cilily)
y"
,ignature of Iunn applicant i
date
Ichi i.al I,:,w