0116 REAR HIGHLAND AVENUE - BPA-09-199 j 13LY131AC. PR( Wl -A "t
APPLICATION FOR PLAN EXAMINATION AND BUILDING nimrr l
ALL STRUCTURES EXCEPT 1 AND 2 FAMILY DWELLINGS J
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name ' hQ OIO O uildi_ ng _
Property Address 644.
Map#
Located in: Conservation Area YtN Historic district YiN
Use Groups
(check one)
Residential(3 or more Units) R2_
Type of improvement Residential(hotel/motel Rl _
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration Business B�
Repair/Replacement_ Educational E_ -
Demolition_ Factory(moderate hazard). F'1 _
Mov✓Relocate Factory(low hazard) F'2_
Foundation Only High Hazard It_
Accessory Building_ Institutional (residential care) 11 _
Other(describe) Institutional(incapacitated) 12_
Institutional (restrained) 13
Mercantile M_
Storage(moderate hazard) S I _
..+` Storage(low hazard) S2_
OWNERSHIP INFORMATION(Please type or Print 1., -1 Clearly)/�
OWNER Name kVl�i Ciotad( �a�-(
Address QJ 2 ?rs-a- I Q 2yvt
Telephone C/ 7 g '7 45 p( S'4
BESCRIP'FION OF WORK'1,'O BE PERF)MRMF.B
`Mom oua lydi'l ed EYcs7 i km r)r4ce s4a�c
FED CONSTRUCHON COST v, (/✓` • O"
J
CONTRACTOR INFORMATION�tC EI-14't� 16<-<J
Name
Address a4 t Ic'� C n� 0 s u 7
Telephone UO
Construction Supervisor's Lic # 3 , f p
+6
Home Improvement Contractor# �)
ARCHITECTX.N4;LPERYNFORMA"F ON
Name
Address 0 q Lr SS lC S
Telephone 7 �!
Mass. Registration # & —
PERMIT FEE CALCULATION
Resi
Commercial est. cost x $111$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signe 9
L D
Date Z
(, ~V
CITY OF SALEM
PUBLIC PROPRERTY
TMENT
DEPAR
d 11 ,t N 1 i 1Q] T 0 NAI I M. N11\1i\( 1: 1; 1 1
I T I 978-'45-9;93 * 1:\X: 1)78 174.- '646
Construction Debi-is Disposal Affidavit
(I-C(ILLil-ed lt)r all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debi-is, and the provisions of%1GL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposedof in a pruperly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(nanie ot'hattler)
The debris will be disposed of in
(name of laolity)
(addrussufacilitv)
signature of permit applicant
9-22-6C-- _ ___
date .
ARCHITECTURAL DESIGN AFFIDAVIT
PERMIT NO.
TO THE COMMISSIONER OF INSPECTIONAL SERVICES DEPARTMENT:
I STATE TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF, THE PLANS
ACCOMPANYING THE ATTACHED APPLICATION CONCERNING THE PROJECT LOCATED
AT 116R Highland Avenue, Salem, MA 01970 INTERIOR RENOVATIONS
ARE IN ACCORDANCE WITH THE REQUIREMENTS OF THE MASSACHUSETTS STATE BUILDING
CODE AND ALL OTHER PERTINENT LAWS AND ORDINANCES.
Paul Durand 8615
Architect- MASS. Reg. No.
Winter Street Architects, Inc.
209 Essex Street, Suite 300
{ R, Salem, MA 01970
cep} s s ;:,,; Address
OF tggS ! 978-744-7379
Phone
August 12, 2008
Date
THE ARCHITECT OF RECORD PERSONALLY APPEARED AT THE SITE OF THE ABOVE NAMED PROJECT
AND MADE THE OATH THAT THE ABOVE STATEMENT BY HIM IS TRUE.
4L9,1if
Afore m
My Co miss on Expires
CONSTRUCTION CONTROL AFFIDAVIT
Date: 7/11/08
PAUL
cGi'�/1'i
Project Title: Opthamology Offices
t R '�._.
Hflfi
6 U ELEC'iR�q
Project Location: 116 Rear Highland Ave., Salem MA e NO 3Gi th
�oo9F�15TEt�� ate`
Scope of Project: New office layout ass/ONA!EN�'v
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS Sfi j �BUIDING CODE,
A-2-TAI�MASS. REGISTRATION NO. e I, 3' 4
BEING A REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE
PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS, AND SPECIFICATIONS CONCERNING:
Civil Architectural Structural Mechanical
Elec= x Fire Pro ection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I OR ASSOCIATES SHALL PERFORM THE NECESSARY
PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR
AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH
THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR
THE FOLLOWING AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction contract documents as submitted for building permit, and approval for conformance
to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components
requiring controlled materials or construction specified in the accepted engineering practice
standards listed in Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY.
Gl/� �oommallri���1� ,
oard of Building Regulations and Standard$
onstruction supervisor License .
Lice e• CS 34940
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9lrtltdate'=�1pf1711953 -
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RICHARD E QOW
I; 115 VINAL STD
REVERE,MA02151 -`" ~ Commissioner