207 HIGHLAND AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
ly •3 Department of Public Safety
State Budding Code I;BU C\Ile)h•centh Edawn I
City of Salem
1 BuildingPermit Application for an Buildingother than .1 1• or 2-Fa it elli
I ihts 1s•Cuon Fur Ulfiaal U<e Unly)
liuddmg Permit Number: Dale Applied: Building Inspector
SECTION 1: LOCATION(Please indicate Block 0 and Lot a for locations for which a street addres s not available)
\o..uid S� Cite r iuwn Zip Cade Name of Building( f applicable) �.
SECTION 2:PROPOSED WORK
It New Construction check here Our check all that apply m the Iwo ruws below
-- - E.cr>tfng-BuddinF 0--Repair --Allerelwn-0 dditiaa -For-04Please-filk4ut-ami-submit-AypraJix
Changeuf Use C) Changeof Occupancy A'Q Uther ❑ Specify:
Are building plans andlur construction documents being supplied as part of this permit applicatiun?-r„Yes :No Cl
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
xt7 tY• Go:- Z ow /t7 G'� -F ��oti-- G' rC—f
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADD
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0
Existing Use Cruup(s): P:uposed Usa Group(s): i
Existing Hazard Index 780 CMR.34: Proposed Hazard Index 780 CMR 34:
SECTION C 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 is applicable)
A: Assembly A•1 0 A-2r ❑ A•2nc❑ A-3 ❑ A4❑ A-513 B: Business ❑ E: Educational ❑
F: Facto F•1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ I-2 ❑ I-3❑ I-�❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage 5-I ❑ S•2 ❑ U: Utility❑ Special Use O and please describe below:
Specal Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) '
IA ❑ 180 IIAO its IIIA0 1118O IV 0 VA ❑ V80
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for delails on each item)
Water Supply: Flood Lone Information: Sewage Disposal:
French Permit: ' Debris Removal:
vka,hc 0 CIgcL J,ndsnle il,.•.I dmv O Indicate municipal❑ A trench will nut be Licemed D"p, of �tle❑
I' c❑ — required 0 or trench r�perdc.
prrmn is O
I
Itailfoid right-uf-way: Hazards to Air Navigation: \D\ I hob•n, t . nnu,-......It„•,,, ;•..
\rl \I•)•In,ildv0 I I��tru.tuic „ilhul.nrpnnl ep)•udds.ur.l' I• lhcrt ir,ieo r, ml•Ia,J• i
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SECTION 8:CON TENT OF CF.RTIFIC.1 iE OF OCCUPANCY
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16r.ibv l•uil,linq„"nlein.11, �l•nnllvr>l ivm `prriel�1 pu 1e111 111. —__.
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'sine.u+J .\Jdrta>ul I'ruperle Otcnrr —�
I \.nne tl'rint) Nb.and Street (lit , r.uvn _.Lila
I'n t)a nee Contact INurmdltun:
rifle rrirphune Nu. Ibustnrss) relephune Nu. (cell) r mail ed.(rc-s.
If.Ipp6cablr, the prupertc owner heretw authorizes
Name >Ireet Addrev Crtyi mien S1.Ve lip
to oct. n the .ro Ivrh .nc ner',behalf, m all matters relame it,work authnnzed by this buddin • iermn a + dicatum.
SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
III hud.hn•is IYss dun Ji.lxtUcu.It.of vnclusad++ace and/m nul wider CGnulnutmn C.n+tnrl than check here O and.k. +fit•.bun to 11
10.1 Registered Professional Responsible for Construction Control
1.�+ Wt.�'I�'L � yl tytSNta'lrivt. 9 WV-1;
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e e u e o. r-mat rrss r utrah m Numbrr� rI
f s�//
Street Address City/Town tit.to Lip iscipl - Eapuanun Gate
10.2 General Contractor -
L.a r S d C111 5 tar/C4/
Company�y smr:
ml,n z Li � 2 h zi—f3
Not a of Perstm Resyttnxibir fur Cunstructiun License No. and Type if Applicable
T Q F/r ,L /. S 41. 1
Street Address City/Town Sta e t -
22Y _ B�PVSd�2PdCnSy✓YrPo ��OM-�
Telephone No.(business) Telephone No.(cell) -_e-_male address
SECTION 11:WORKERS'COMPENSA ION IN URANCE AFFIDAV (M.G.L.e.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial AccidentsjbuP1J,,tn
leted and
submitted with this application. Failure to provide this affidavit will result in the denial of the iss lding permit.
Is a signed Affidavit submitted with this application? . Ye No
SECT ION 12:CONSTRUCTION COSTS AND PERMIT FE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6I. Building f t OG C7 Building Permit Fee-Total Constructi (Insert here2. Electrical f (�Q appropriate municipal factof GGGd. Mechanical (HVAC) f 0 Note:Minimum fee=f (cpality)
S. Mechanical (Other)
Enclose check payable to
6. Total Cost - f I U (contact munici alit )and write check numlxr here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
HY rnienng my name below, I herebv attest under the p,nns and penalttev of perlury that.dl of the mLirmation co-nt.uned m this
.+pgplicalwIn is Irue end occurme to the be+t of mP knawledge.tnd understanding.
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I'I�•inch•nnl iml -ign n.+me // rifle l"A •h'-n —
�I n'cl \.Llr,— lift/ruts rt
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I \lunicipal Inspector to fill out this section upon appliolisn approval:
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