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0227 HIGHLAND AVENUE - BPA-07-856 MKT BASKET EITY"OFg -- PUBLIC PROPERTY DEPARTNIEINT IGWFJLhY ORl5CW1 �S� �`� KAYO! 130 WARwwnw s mw•S^+ai NAssAcxM-1n 01970 14197674E-9S9S 0 FAf¢976740.9W APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRU OR BUILDING 1.0 SITE INFORMATION Location Name: m�r 1 J�sk¢ Building: -- - Property Address: -- -- - - Prop"is boated In a;Conservation Area Y/N f�_Historic 01strkx YIN 0_ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: 091 As7 Sr, ( Ci.,)4spt) y Telephone: q 7 b'sl 6 Z 6 d 3.0 COMPLETE THIS SECTION FOR WORK IN FX18TINn BUILDINGS ONLY Addition Z Z 1 S Existing Renovation Number of Stories Renovated Change in Use NSA New Demolition Existing (et a o c> Approximate year of Area per floor(so Renovated 1000 construction or renovation lIg of existing building New i zj Bdef Description of Proposed Work: hh 1 �1�� pro [�'� ucC goo e,-� GDv� Ev I rcI&Ceic e xisi i h ccxSes P \ 11 II II Pi,,J 10i V bz 1 ,)d, II Qd ,}(�Qxr crA cocA c e, 5 .. ( or - .0 1 WG 1 �A� -S - + --� h ` o5 I---mil - -`�, 1,--------- - - Mail Permit to: w, I o c.IC (0 6 9 Z4 3 d3 is sG�wP Sfi. SR n What is the current use of the uilding? Material of Building? CrA L) 51-Q if dwelling.how many units?_— Asbestos? n�U Will the Building Conform to Law? m,�� g� Architect's Name '�C Q� y'S1 b Z,O D o I l Address andphons jZMD llu 6�5 hSs k JS�L1� y �' YlA Mechanids Name PP !v 634s� Jaw e s `Z z M c II ) )1) Address and Phone I 9•rin Cna) .I r� � n� 145 (jfbV� 5j '� '. �°r NoV U1��✓� /1' Constuction Supervisors License# c s c.s g g HIC Registration# Estimated Cost of Project S LQ OOU Permit Fee Cak;uWW Permit Fee= 1(o S '�— s or Estimated Cost X$7/$1000 Residential Estimated Cost X$t 1 t$1000 Carnmercial--- --- - An Additional SS.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays In processing. The undersigned does hereby apply for a Building PermKA build to the above stated specifications. Signed under penalty of perjury X Date N 0 ; � s g CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ncnearsntav naacou MAtroa uo wtiomreroa„s�aesr•s,u�ae, trs01970 Tot-MNS-M •FAX-M7449W Workers' Compensation Insurance AlMdavit Bulilders/ContractonMe��n/pbm A \\ bers Name i �: rnh� GnPJ)61ZLYT1A,nl Dt;v.',' OPAXA1T / Address: i SJ t > Ciry/State2ip: Pe je �orou� r t �' ne 603 Zd 360 3 An am o employer?Cheek the appnprlats bast 1. 1 am a employer with 4. ❑ 1 am a Small and IFORawdcling ngoleed): employes(&a and/or past'dwa).• have hired the wb•contrutonconstruction 2.❑ I am a sole proprietor or paemee6 listed on the attached sheet t ship and haw no employees Thee sub•conerac�hawworking fbr me is any capacity. workers'Comp.in�e(No workers'comp.inwmnce 5. ❑ We ate a carpontion and its dition required.] oHlcen haw exercised their 10.0 Electrical repairs of additions 3.❑ lama homeowner do' all w right doing ark of � M(1L 11. myself.(No workers'comp. c. 152.¢1(4e 1��no �Plumbing�Ts or addle°°: uuauanerequired.1 t employees.[No workers' 12.C]Roofrepaim comp,insurance raxluired.) 13.❑Other t*A" Y ea m.m ale utr bu ee one td atao w wx dw seem.edm r6ewtar nair.a4.'om1peass"war�a�erta� tCoeuaelsee tlr etteek ddr flea Kerr nth ad N a M01k ad�hhe am"epatlagela=us 111O11 a rear aa1<�WdiceMog jgaL Iho%*dw alma of me and dwk rmdm'Camp.Phi(dhlaamaaa. lam an earploya that bprovidlnB worbas'compensaa►oa insarencejor my employees Blow it rhePo 7'andJol SUSin orwacfon, Insurance Company Name: /i� G C1 1 S U R.AN G Policy N at Self-ins.Lie,A P�1 (�(� C7 A Z rt3 S f � Exp�on Datoc: Job Site Addrete: 7-2-2 lq`e L l c,j A -, Ciry/State/Zip:_J 4i_pL_�IV hN Attach a copy of the workers'c mpesatloa Policy delaratloa pegs(aka the Failure to secure coverageerr �i policy number and expiradon daps required under Section 25A of MGL a I s2 can lead to the imposition fire up to f 1,500.00 and/or one-year impriwm imposition of criminal penalties of a nent,as well as civil penalties in the form of up to$250.00 a day against the violator. Be advised that a copy of this sutmumt may be a STOP WORK ORDER and a a forwarded to the Office of Investigations of the DIA for insurance coverage verification !do hereby cerally a and ponam"of r/ary that the In one I anion provided above Is Arse and correct Phone 0: QQ?cial use on'A De not writ 14 u14 area to be eompkted by city or town oQkieL City or Town: Permltaiceme 0 Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Clty/rowa Clerk 4. Electrical laspertor 6.Other S.Plumbing Inspector Contact Person Phone p: CITY OF SALEM a I ;,ai PUBLIC PROPRERTY ._- ��4�P DEPARTMENT KI\I61'.R LF.1'Uftltii:011, 41n YOl: 120 WASHNGTONSTREET ♦$AITM. MASSACHLSEFIS0197C Tit:978-745-9595 ♦ PAY:978-74&9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780-C-MR sc tl n 111/ 5 Debris, and the provisions ofMGL c 40, S 54; 4 � AJ� Building Permit# is issued wi the condition that the dc�ris 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 he transported by: t hauler The debris will be disposed of in s 8� Scl (nu a of f Ility) J4I ¢ m N w 6 PSIJ�scIC (address of facility) signature of permit applicant 4 5 07 date dcbrfsal'f.duc _� � � � 1� � c��� �� . CONOIT'. ti'�� CITY OF SALEM s DEPARTMENT OF PLANNING AND 9F��rn COMMUNITY DEVELOPMENT I:in mm.ev DRlscou.�'GAVOR 120 WASHINGTON SIRFFT♦$.q[.F,1,MASSACHOSEITS 01970 bNN GOONIN DUNCAN,AICP TFL:978-619-5685♦ FAX:978-740-0404 DIRFCCOR December 18, 2006 -- -- lla Mr.John P. Matthews R.M.D. Incorporated ` 881 East Street Tewksbury, MA 01876-1495 RE: Hawthorne Square Shopping Center 227 Highland Avenue Request for insignificant change Dear Mr. Matthews: I have received your request for a determination of an insignificant change for the Market Basket at 227 Highland Avenue, Salem as shown on revised plans dated July 13, 2006. The proposed changes are (1) an addition of approximately 937 square feet that will be a produce receiving and storage area; and (2) a second addition of approximately 1,375 square feet that will be used as a dairy cooler and refrigerated storage. The existing dairy cooler will be converted to dry grocery storage. A total of six (6) parking spaces will be lost as a result of the second addition. I have determined that these changes to the site plan are not substantial changes and do not require Planning Board approval for the following reasons: (1) The two additions represent only a 1.36 percent increase in the gross floor area of the existing buildings; and, (2) While there is a loss of six parking spaces, the additions do not increase the parking requirement and there are still 10 more parking spaces than required to meet zoning. The revised plans dated July 13, 2006 are hereby made part of your approved Site Plan. Any further revision requires approval of the Department of Planning and Community Development prior to construction to determine whether it is a substantial change. If you have any questions, please contact me. Sincerely, JcpGoomn Duncan, AICP tor ' BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 065838 e Birthdate:-1 012511957 Tr.no: 3958.0 Expires: 10125/2007 Restricted: 00 DAMES R CHEYNE / q 25 SMITH ROAD GOFFSTOV`1N, NH 03045 Commissloner J �nnwxmu�ao y? BOARD'OF BUILDING REGULATIONS' `License: CONSTRUCTION SUPERVISOR 065,838, +.. F gI25J4957 &rthd — P Tc.no: 3958.0)— - Restri JAM CHEYNj ES R 25 SMITH ROAD 0�51"� GOFFSTQWN, H Commisgioner }I BOAR4QF BUILDING REGULATIONS. CONSTRUCTION SUPERVISOR 065838- Number:uCSti 61Ahda18-`�0_2 A95T I E'+� 10I26120QT Tr.no: 3958.0 ` JAMES R.CHEYNE�� J(. 25 SMITH ROAD ii GOFFSTOWN, NH 030Q5Y Cumm�i� . Construction Control Affidavit Project Location: 227 Highland Avenue,Highland Ave, Salem,MA Job No. Project Name Additions for Market Basket-#58 Nature of Project Complete renovation to existing store. Architect and/or Enginner: Michael Ortovksy;AIA /RMD Inc Address: 881 East Street,Tewksbury,MA 01876 Telephone No.: 978-851-0200 In accordance with Section 110 and 116.0 of the Massachusetts State Building Code, I, r l(c Q P— Registration No. j q j� being a registered professional engineer/architect hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: ❑Entire Project 11�rchitectural ❑Structural ❑Mechanical ❑ Fire Protection ❑Electrical ❑Other 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 accepted engineering practices and applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be PP g p responsible for the following as specified in Section 116.2 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 controlled 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 G. Pursuant to Section 116.2.2,I shall submit periodically, ❑daily, ❑ weekly, or ❑ other periods(specify)progress Reports together with pertinent comments to the Town of I ` i {� Building Department. ,Michael Oratovsky,AIA Sip-ature al- r� Subscribed and sworn to before me this J 1 day of tp t, M Loy 7 My commission Expires No lie � y r MASSACHUSETTS SIGNATURE WITNESSING Gov.Exec.Ord.#455(03-13),§5(1) Commonwealth of Massachusetts County of Tn 1 0 9�&S "e )c I SS. On this the _L day of l L before me, Day .� Month Year t"L. C0�JV11 the undersigned Notary Public, Name of Notary Public .I personally appeared _C (44=fc r> r�� Name s)of Signers) proved to me through satisfactory evidence of identity, which was/were t y /1.�rJ of 7—t-�' Description of Evidence of Identity to be the person(s) whose name(s) was/were signed on the preceding or attached document in my presence. DAMES EUWARD CARTER Signature of Notary Public Notary Public ~CPry-" � Commonwealth of Massachusets' My Commissyon Eryiresian29.2010 Primed Name of Notary ^ Commission Expires -Ito I Place Notary Seal and/or Any Stamp Above OPTIONAL Although the information in this section is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. - Top of thumb here Description of Attached Document Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: ©2004 National Notary Association•9350 De Soto Ave., P.O.Box 2402•Chatsworth,CA 91313-2402•www.NationalNotary.org Item No.5953 Reorder:Call Toll-Free 1-800 US NOTARY(1-800-876-6827)