0116 REAR HIGHLAND AVENUE - BPA-12-453 The Commonwealth of Massachusetts
' Department of Public Safety -
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling,
(This Section For Official Use Only) 4
Building Permit Number: Date Applied: Building Official: -
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address Opkaydat,14
/&-R H lga1-f+ND AOF, - SkaAA 14 A
No.and Street City/Town Zip Code Name of Building , t
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in Ve two rows below
Existing Building T, Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
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 �t No ❑ -
Is an Independent Structural Engineering Peer Review required?D Yes ❑ No ❑
Brief Description of Proposed Work: D EM D�./'1%0 1 � .SEZEcTED JLD✓ [3 FA It?✓N �A II�LYteS
e o WS (s a c W PAa�DOA-S PC--f &A — &LJECrfllcA1_ — PL U n l f w
Yeli� r AND /rvlgj4I=s
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 CMR 34) 0
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 2>-N 2-
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business K E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H11❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6-CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB,-)Et I IV ❑ I 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, Check if outside Flood Zone❑ Indicate municipal�[
A trench will not be Licensed Disposal Site lj(
Private❑ permit is enccll or indentify Zone, or on site system❑ required❑ trench or specify:
osed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No PKI Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: ar4 Use Group(s):_A_ Type of Construction: 3 P Occupant Load per Floor: 2 0
Does the building contain an Sprinkler System?: Wo Special Stipulations: No N I
SECTION 9 PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Asar� YS1gA`T (,ouLD /16 411914LAwa AVAr 5 ,4LEA1 NA.
Name(Print) No.and Street City/Town y - Zip
Property Owner Contact Information:
DwtuE(( Cr`�S74J_ -73fi3 SHLEq CPIAtRICcAcNTRL.G 6t"fA/G.Cer(
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
f(lAPeS - fo�1N I" r1-0 c.l WlxltcR ST K 14"V 701-# N'lA oZ36v
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.It 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
�Ety/S CDLtC!✓ cj�_ 2TL0 4.7Dg [,Ew60LTENAIMGP1OIL "M 4P540
Name(Registrant) Telephone No. e-mail address Registration Number
C1 VE0.Not-/ ST F rflru9HAu1 AA__ QtL APr1t OV11 ?-
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
-MApES LLL tyaMN MAT6P✓
Company Name
t�H t� / �A'T T3a�✓ CS I U g4S
Name of Person Responsible for Construction License No. and Type if Applicable
14 w/WtIEFk T, K/rwq.�/(J/✓ Mh 0236c1
Street Address City/Town State Zip
-f 603X .4n 099.E IRHDESLL-c tilafyoo c0P-1
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.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 a signed Affidavit submitted with this application? YesK No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ •490 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ a ,Oa appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ D , (Co.tact municipality)and write check number here
SECTION 3: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
appliHIP isM�and3 0�te to the best of my knowledge and understanding..
1✓ PRFS ^rEHQEf, D-eV
-Please print d sign name Title' Telephone No. Date
Street Address City/Town State Zip'
Municipal Inspector to fill out this section upon application approval:
Name Date
RR
"Massachusetts- Dep:uYment of Public Safet.
1 Board of Buildin Re-ulations and Standards - -
Construction Supervisor License -
License: CS 14895 �..
JOHN P MATTSON .f }
PO BOX 369
KINGSTON, MA02364
Expiration: 9/1 012 01 3
f'onmricsioner Tr#: 3400
155ACHUSET1
DRIVEF SLICENSE !: -
��S61221455 art £
09 10 2013 09 10-19
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�� JOHN P rTTa
l 4 WINTER ST
KINGSTON,MA s r r' w3'+ir �yu -
p 023 6 4-111 5
e " e�R'1M19a2 k '
Office-f .04-0-1 m.ms k'BgTsin'V egu ah
+ _ HOME IMPROVEMENT CONTRACTOR
T' Registration ,131446 - Type: ((j
Exp"ration: 7l24/2012 - Ltd Liability Cor2o,
t
i'. T SttL
JOHN MATTSONti y!
. P.O. BOX 369
Undersecretary
-KINGSTON,MA 02384�
-.,�
P • �slC
xUS ETTsCI1Y ofS_�`tLL
BuIlD \G DEP*.RT%lE\T
OV1?0w.uHNGTSTREET. "'F ,0AA
�_ F . 15-9595(978) 7.0-9M
KjJffiERLEY DFUSCOLL M-iom&r ST.?MnE
MAYOR
DIRFCCOR of V'L'tlL1C PROPERIY/EL'IIIDtNG CO\MISSIOTER
CONSTRUCTION CONTROL DOCI;NIPNT
Project Title: Dr. Gould Dental office Date; Oct 25th. 2011
Project Location., 116 -r Highland Ave. salem Ma.
Scope or project: _ In existing Space do Entire project control of construction of a
dental office
In accordance v,idi SEC ION 114:0-116.42 of the 6th edition of the Massachusetts State Djilding Code :
1 Lewis Colten AIA Mass. Registration NItmhrr
bcint;a rcgistered profcvional [ngineerfArchitect bereby CERTIFY that 1 have prepared or directly supftvtsed
the ptcparelion of all design plans, computations and 5petiGCalit3W e0-.1CtFlling:
D4 Entire Project ( j Atchitectural ( [ Smicm:al [ j Mechanical
1 j We Protection [ ] Clet.ttical ( j Othcr(spccify)
for the above narned project and that to the,hr-et of my knowledge, such plans. computations and apecifteations meet
the applicable pruv 6ioas of the Masmchusetts State Building(title,ull acceptable ca&eering practices and all
applicable Uwe ror the propozcd project,
1'wthcrmore, 1 undustand and ACUKE that I-Jnll parfotm the necossary profebsional crrvices and be pr ient on
the coostructiun bite on a regular and po-nottie basis to determine that the work is proceeding in accordantx with the
documents approved by the building permit and;brill be resputGtble for the following as specified in semon
1 1 G.Z2:
1. Review of shop drawings, samples and otter submittals of the rnntrnctnr as rerpttrM by the enncmtctinn
contract documents us submitted for tic building pctmit,and approval fur the curtfurmantx to UK drsiga
ton"pt.
:. Review and approval of the quality control procedures for all code•requued controlled tnatcrials,
I 13c present at intnvule opp,opriate w the stage of construction to btxeme gen Tally familiar with
the progress and quality orlhe wnrk anA to rirtrrmine, in general, if the work is being performed in
a rnanacr consistent with die construction documenm
t shall submit periodically, in a lorm accciamble to the buitdidg 6IMttul,a progress report togetbee with pen next
conttrtants. Upon completion of the work, f shall submit to the building official a final re olA c to the
Satisrtvanry,romrirlinn and readiness of the project for occupancy. ►PEp ARCyi
c s cocrFiFc,�
Signature and Seal of registered prortssio to
NO.6540 w
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o�
q'TH OF MPsjP
41
CITY OF S�U-ENI, INLNSSACHUSETTS
• BUILDING DEPARTMENT
• N 120 WASHINGTON STREET, 3' FLOOR
TFL (978) 745-9595
FAX(978) 740-9846
KI.\tBERL.EY DRISCOLL
MAYOR �tOntAs ST.PIERxs
DIRECTOR OF PUBLIC PROPERTY/BU;ILDIING CON12MRSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
GCAPES Z.L C
(name of hauler)
The debris will be disposed of in
a 161 .j 4� Ro Leo,--, /vl /L
(name of facility)
� 41)r_ESfi
(aadress of facility)
32-
signature of permit applicant
date
JcbrisIi.Joc
Ac� CERTIFICATE OF LIABILITY INSURANCE
B 2 31
THIS CERTIFICATE UI ISSUED A8 A MATTER OF gFO/flIAAT10N ONLY AND CONFERS NO RONTS UPON THE CERTIFICATE HOLDER 71iS
CERTIFICATE DOES NOT AFF001AATAAELY OR NEGATRIELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IRSURERS), AUTHORIZED
REPRERENTAIIVE OR PRODUCER,AND THE CERTIFICATE MOLDER
MPORTANT: M the CBril11Wb holder is an ADDITIONAL INSURED.ills POliCY(ee)mist be endorsed. SU8RDGAMON IS WMIER SUN at tD
ft terms and Corrlitlorra of the polity,CG'bd Pofieiea NeY require an endorsamerlt A ebtameet on tMs earONab does not eanfer r%bfi b the
eartifiaate holder In Has of such ardorserw
NIOUXIER
Russell Tudor insurance Agency Rloxe 78 58 -6 50 . t7e1) 5es-5465
5 Kingston,
n, MIL A 'im russelltu orins.coe
Kingston, MIL 02364 P 5325
AiS111E AFFORDINr CDVEPAOE NMCa
�� INWAS/A:Arbellg Protection Co
Trades LLC - INruRane:Tlart£ord Insurance
POD 369 wUR c:
Kingston, NA 02364 MNRERO:
INeIRIM E-
i R91Fo
COVERAGES CESRIFICATENUMEER' REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATE. NOTWTCHSTANDNQ ANY REQUIREMENT TERN OR CONDITION OF ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESOnSED HEREIN IS SUBJECT TO ALL THE TERMS.
ERCLUSONS AND CONDITIONS OFSUC H POUCIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMIS.
LWInPi ofINSURINLE A vDu NI r n raw 4MRe
aD6a1AlE.AUr
EACH MCUPRENCE 5 000 000
A caLEraRALLRaLiTr 8500043712 7/3/11 7/3/12 D GE RENTED S 10 000
❑06UR NEDEIP(AWOM e.P i 000
PERSONALS ADVINNRY 0 000
OENERALAGMtS TE i 2 O Q 00
EEMLACCReGATELMITAPPIESPER PRODUcrs-ODNPMPAGG 6 2 O.0
POLICY M LOG i
AUMMOOMMMu1T C06evby8N4MrLMR 6
ANVAUTO (fiamidan)
A NE LOWDAUTOS
aaDILY MA/RY(Per Aaem) 6-
SCHEDULEDAUMS eOMLYIN.NRYryvscdm0 i
HIREDAUTOS PROPERrYDAYAM i
!P>emesre)
NONOWMI)AtrrOS i
6
Emess AUAB OCCUR EACH OCCURRENCE i
FxBe LIAeWI
A lE
A=K
fIOy
DUDUCTeIE
RETENn0N
f
B RND8APk WuAaLn OBNBCLJO669 8/3/11 0/3/12 wcsrnrU- UM-
AWFR PLOYERS'MRMW
OFFl�MEieERE D? Y� N A 0E.L EOCH ACpCEM S 1 DBD D00
P/I.NANry N NN)
r CaRreewNx EL.N6EASE-EAFAPI.OYE i 1 000 000
D "sCRPnDN DPERATronsmNw PL.615EAN-POUDYLNrt I S 1.000.000
MOMPTIOR OF OPERATRINS I LOOKTOM IVENCLES (Aft"POUND 101.AMtlgNI MMA.9N .,it .pa FgMg0 tl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF 7NE ABOVE DESCRIBED PO ess at CANCELLED eEFORE
TRADES LLC THE ERPIRAnON DATE THEREOF, MOnOE anLL BE DELIVERED N
ACCORDANCEenTN TINE POLCY PROVI$WNe.
POB 369
KINGSTOR, NA 02364 AUTHOROo REPRE3"TATNE
®1IMB2009ACORo CORPORATION. All rights reserved.
ACORD 25(2009U09) The ACORD come and logo are regiebrod marts of ACORO -
CITY OF S. .E,NI, NLASSACHLSETTS
BUILDING DEPARTJlE.NT
p• 120 WASHINGTON STREET,3'a FLOOR
taaebj TEL (978) 745-9595
FAX(978)740-9946
KIN
iBERLEY DRISCOLL THONIM ST.PMRRRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CO%L\DSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Menge Print Legibly
Name(Busimx� orsatnizatiowindividdpu —}-al): 1 1 ` t"l O z .-
Address: L1 W//'U 1 G#I,-
City/State/Zip: �� 1� �7a � hA/ 029 /Phone #: 7B/'—S?--S--483S?_
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with Z4 4• ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§10).and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13❑Other
comp.insurance required.]
*Any applicant that chocks box 91 must also fill out the section below showing their workers'compenation policy infurtwion.
'I Inmcowtxaa who submit this affidavit indicating they ate doing all work and then hire outside connactor most submit a new affidavit indicating such
=C,,ntm on that check this box most nached an additional shsl showing the morn,of the sub fflracton and their worker'eomp.pot icy information.
1 am an employer that is providing workers'rompensadon insurance for my employees. Below/s the pollcy and jab site
information. ,
Insurance Company Name: V�Lj—»Q _.y.�ftO��G:riO NCO. LI Rk'F K D aSu�fl A14C
Policy#or Self-ins. Lic.#: O 13 e- Expiration Date:
Job Site Address://` H /q{1LAPJP A0C City/Stare/Zip: SALE-Al M
,mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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 fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Into hereby cerd coder tl a pains mod naldes of perjury that the information provided above is true and correct
ire Oate:
Phnri X: 7 / �63P
Offrcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority'(circle one):
1. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#: