248 HIGHLAND AVE - BUILDING INSPECTION (2) 'A
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The Commonwealth of MassachusetEs
�;, �,�, Department of Public Safety � Z �
, . �➢U ` Mass�chusetts State Building Code(780 CMR) � ��� ,
� Building Permit Applica[ion for any Building other than a One-or Two-Family Dw ing n
� � � � (This Section For Offici2l Use Only)-� � � �� - {. � ~� -
1
� `�� Building Perrtiit Numbec � � . Date Applie�i: �.�Building Officinl: ��. . �� � � � ' Z� �,
� �►+ SEC'CION 1:LOCATION(P(ease indicate Block#and Lot#for locations foi qwtiicti a street address is not available) r'�� '
� ' \ g ,�^�c/a,�a.'� �!/E �'`.�-/�ff, ll�rwylth �av�.✓Tfi
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No.and Street City/Town Zip Code Name of Building(if applic� C. - '..
� � � SECTiON 2:PROPOSED WORK. �. ' - � . �� � �p r+r � �.
Edition of MA State Code used_ If New Constcuction check here O oc check�ll that apply�in the lwo rows bclow �
Existing Building 2ep�ir❑ Alteration B� Addition❑ Demolition ❑ (Pleasc fill out and submit Appendix 1)
Change of Use ❑ Change ofOccupancy ❑ Othcr ❑ Specify:
Are building plans and/or construction docwn�nts bcing supplied es paet of this permit�pplication? Yes No ❑
Is an(ndependent Structural Enginccring Peer Review required? Yes ❑ No ❑
Bricf Description of Proposeii Work: �qfs�C�dt-7 d �C I.�� � ��A-Ti�✓rYt �d✓ -v�Gl.c�
�[�/a,� /�N i%'
SECTION 3:�COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
� � � � � CHANGE IN USE OR OCCUPANCY � � � � � �
Check hcre if 1n ExisHng Building Investigation and Evaluation is endosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECT[ON 4:BU[LDING HEIGHT AND AREA � - � � �
Existing Proposed
IVo.of Floors/Stories(indude basement levels)&Arca Per Floor(sy. ft.) �pLT p-
To[al Area(sq.ft.)and Total Height(ft.)
� � � � �� � � SECTION 5:USE GROUP(Check as�applicable) � � � � � � � �
A: Assembly A-1❑ A-2❑ Nightdub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: EducaHonal ❑
F: Facto F-1❑ F2❑ H: Hi h Hazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: InsHtutional I-1 ❑ I-2❑ [-3❑ [-1❑ M: MercanHle❑ R: Residential 2-1❑ R-2❑ R3❑ R11❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use 0 and please describe below:
. Special Use:
� SECTION 6:CONSTRUCTION TYPE(Check as applicable) � - �
, IA ❑ I6 ❑ IIA ❑ 1[B ❑ IIIA ❑ IIIBO N ❑ VA ❑ VB ❑
� SEC7'ION 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 f� Check if outside Flood Zone❑ Indica[e municipal❑ A trench will not be Liccnsed Disposal Site❑
required �or trench or specify:
Private❑ or uidentify Zone: or on site sys[em❑ ��rmit is endosed❑ �
Rallroad[i bo -wa : Haza[ 9 to Au aVl a[tOn: ill\i Int �ic C nnnussi�n K .u�� I ri- '
S Y B _ ...._�.._ .�_ .-. is.��•
Not Applicable❑ Is S[ructum within airpor[approach area? Is thcir review completed?
or Consent m Build endosed ❑ Yes O or No❑ Ycs❑ No ❑
SECTION 8:CONfENT OF CERTIFICATE OF OCCUPANCY � . �
Edilion of Code Usc Group(s): Typc of Cons[n�ction: Occupant Lu1d per Floor:
Docs thc building con[ain an Sprinklcr System?: Special Stipulations:
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� � � � � � . � � .,: SECTION9:��PROPERTY�OWNER�AUTHORIZATION � � -
. Name and Address of Property Owner' �1/ � ' .�
�eu ra ���"v�� ��(O /����'!�i.
IVame(Print) No.and Street City/Town Zip .
Pioperty O�nec Contac[Information:
r�
ry -- �-�-�e� - -
rTiNe � � 'I'elephone No.(business) Tclephone Na (cell) e-mail address �
t[f appficable,Hie property owner hereby authorizes =+
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r '^' {Name � StreetAddress City/Town State Zip �
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to act on the- ro er owner's behalf,in all mat[ers rcl�tive to work authorized b this buildin ermit a lication. -
_.. . .,.�. . . .
� ��� � SECTION 10:CONSTRUC'I'ION CONTROL-(Please fill out Appendix 2)-. "� ' � � �� .
e:TF buil4dui �is Icss than 35,000 cu.ft of endosed s ace and or not unAer Construction Control ihen check here��and ski-Sedion 10.1
10�1-2e��istered Profession5(Res �onsible�for Construction.Contral �:., �.� ` ` ' � �� �. �,. � � '�
Namc(2egistrant) Telephone No. e-mail address Registration IVumber
Strcet Address - City/Town State Zip Discipline Expiration Date
� 102GeneralContractor - � ��"� "' ' ��`�" �" ' � � -
Q.G �Q cR�,�,�v►-✓QT�e>1 s.�-
mpany Name �S �
0,�� �2� a tr�4� ��
Namc of Person Responsible fur Constructiun License Nu. and Type if Applicable
� aY �a'7 �,e�.aboo�-� ,�� �6� -
Strect Address City/Town , State Zip
-� Dlcl _-_ �.�I��bLt'orSpYVCTJaN�'v.�_ NOVV1 -
Tcic hone No. busuiess Tcle hone No. cell e-mail addmss
� � �� � ��:SECTIONII:�\it�ItKP.RS'<UA�IPFNbA'l10\'tNSU1:A\<.t1,Af-'.FIt)r1VCl' M.G.L:.c.152: .25C6 =
A Workers'Compensa[ion[nsurance Affidavit fro�n the MA Department of Industriil Accidents must be comple[ed and
submitted with this application. Failure to provide this affidavit will result ui the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with this� licaHon? - Yes❑ No ❑
��-�� ''��SECTION�12:.00[YSTRUCTION COSTS AND PERMIT FEE� " �
Item Estima[ed Costs:(LaUor
1nd Materials) Tot�l Cunstruction Cost(from Item 6)_$
. 1. Building � !O � � guilding Permit Fee=To411 Construction Cost x_Qnsert here
2.Electrical � appropriate municipal faztor)_$
. 3. Plumbing $
d. Mechanical (HVAC) $ � Note: Minimum fee=$ (contactmunicipality)-
5. Mechanic.il Other S Enclose check payable [u
6.Tolal Cost $ (contact municipality)�nd write check number here �
� SECTION 13:SIGNATURE OF BUILDING�PERMTT APPLICANT.�> �
� By entering my name below,I here n[test under the pai and penalties of perjury that all of the information contained in this
application is[rue emd accura[e b e best of my kno��� �e and understanding. /
�vl r.�✓-�-� �r�Si�l,w T. �� _QnS' 0/96
Please pr it and sign nan Title Telephone No. Date
�✓. %�i-� 5�� �e�d�•?�i �i �a�6_� -
Struet Address City/Town e Ziy
Municipal Inspector to fill out this section upon application approval: � � '� `� - ��J� �
. . �. . . . � . . Nwie � � Date .�
. .
;T° CI"I'Y OE S.1LE.�I, l�L-1SS:ICHL'SETTS
� Bl'ILDL�G DEP.\RTIE.\T
� � ����� I?O1X/.i5H4�IGTON571tEET, 3�OF100R
'. ��' 'I'F� (978) 745-9595
• � Fnx(978) 740-98�i6
(���gFar FY DRISGOLL
{;1�f.1YOR THonr.�s Sr.Pi�xs
DIAECi'UA OF PL'�LIC PROPEATY/BCIIDII�G CO\L�1I55fONER
Wnrkcrs' Compensation Insurunce A�d•rvit: Buildcrs/Contractors/Electricians/Plumbers
A�iplicant infnrmatinn Ptcase Print Le2ibIY
l44� /�on ST "/�
VfI171C Il)a�in¢ssO�ganirarinrvinJividu:J): , ��Td✓f ..�l�D— � •
f��C�fl'�5: WQ x �� 7 •
Ciiy/State/Zip: �'�+�r ✓!/lA.t` Phone N:_rJ� a $ , go 9 -o/ S �
Arc y� n cmployer'!Check the•rppropri�te Doi: Typa of proJect(rcqulred): �
1. I am a cmployer with 4• 0 ��+n a gcncra)conlme�or and 1 6. ❑New cunnWction
amplayeea(full aml/or paa-�ime).• have hired�he sub.conuactory
� 2.0 I am a sole propriclor or puAnary listed on�he attached:�heeL = �• ❑aemodeling
.hip�nd have no cmp�oycon These sub-contrecrors havo 8. �Dnmolition
wurking�ti�r me in:u�y capacity. workers'comp. in�u+anae. 9. ❑DuilJing ad�itiun
�No workcn'comp. insumnce - 5. � We are a carpnration and iu
rcquircd.]
oi'ficen huve ezereised thu(r ����t��crrica!rcpairo or�ddi�ions
7.❑ 1�m a homcuwncr duing all wurk riyht ntexrmplion per MGG I I.Q Ptumbing rcpuin or udditiam
myself. [\o�vorkcrn'cump. c. 152, q I(4),and wc hava np �2,0 2oof rcpairy
insuranca reyuired.) t �mpluyeee. �No wor&en'
cump. iiiwwncemyuired.J 13•OOthar
•Any uppliv:ml dut rh�ck�buv!I m�u�aisu fill uul tlie ttcliun below ahawiny Iheir wod�n'<umpenaadun puli�y infurmaHon.
�I Inmcuwn.n aho rubmil Ihis a1TIMvi1 indieming�hcy am doinW oU wod[and IhCn M1irC uYtfWetonlmctma mml fi�hmil a xw afBJavi1 indiafiny xuch.
�C�mu:�.wn�hW ch�ek thi�Eux mmt anaand an aJdi�iuml ahnl ahuwiny Iha nyn.of tho,ubavnlnpun anJ iheir wnAcn'wmp.pullry infumuiion,
/unt r+n rntpluyer lhat li pruvidlnK ivorkrrs'cuniptnaadan inruruueejoi my uepluyrrs. lfeluiv Lv�he pollcy undJub r!/a
iujwn+winn.
Inwmncc(:om�any Vmne: $ �QT�v� _�i�s S
Nulicy il ur Srlf-iim. Lic.N: ___ Expirulion Dalz: �
lub Siit AdJress: ��I 8 Il/'c���"�C /L`C' Ciry/Stau/Zip:. �i'G,/'��
,\tt�c6 •r cnpy uf Ihe irorleen'compensutloo pulley doclaratlan pa�;e(shawing tha pullcy num6e�and explra�lon d�tu).
F�iluru w wcurc covemge;u mquireJ unJar Section 33A uP�fGL c. 132 ean IeaJ io Ihe imposieion afcriminal pena�tie�ofa
rine up to SI.SOO,UO unJ/or mu-ytar imprisonmcn4�s wcll a.v eivil pcna(tics in lhu(omt u!'a STOP WORK UR�ER anJ a lin�
nf up to 5?i0.Q0 u Jay against rhe violatnr. 13e aJvixed th�t a copy uf�bis st�tcmeN may fw funvarded lo thc 011ica of
Invrs�ig�iiun.r�il'ih�nIA fur insunnce coverogc vcrilira�iun. -
/du/�tirby rrrr' m�Jr�Ihr ulnr uuJ �r�i rs o�perjary�but d�e in�unuutloi.pruridcJ uGo u is�r/'�and currrct
Si,•n � r' Uat�• ��__ / /�
Phune y' �D ' ��� � �// '7
D%/iciu!use only. Oo n✓f ivrilt in Ihis onu� m be comp/e�ad by riry ui io�un o/JJrIuL �
City n�'fu�rn: - -. Nermit/IJrnnec q • f
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Is.ruink.1 W hurily(tircic unc): I
I. ISu:irJ uf Ilr�l�h 2. IluildlnG Depar�ment .1.fi�yffu��n Clerk A. F.Iectrir�l Inspc.tur 5. Plni�i6iug Insp.uor I
G. I)�6er
� Cunt�ctl'crtnn: _._._._._ Phnne ;t: �
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�.��, C�7'Y OF SALEM, MASSAQ�USETTS
�K S,c ���r1 BUILDING DEPARTMENT
\, �,,,„ �" �� 120 WASHINGTON STREET,31D FLOOR
� � T�L. (978)745-9595
FA�c(978)740.9846
KIMBERLEY DRISCOLL
MAYOR TY3oNrns ST.P��
DIREGTOR OF PUBLIC PROPERTY/BLIILDING COMNIISSIONER
Construction Debris Disposa/ 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 c40, 5 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
YG /S Ao�.r S T!'o a�i o,'! —�
(name of hauler)
The debris will be disposed of in:
,
s�-/�
(name of facility)
�, 7 Gi��.s 7io�IP �'T� , ��o�dj� �J� .
(address of facility) �
ignat re o applicant
/ � /
ate
. �
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NEW I1VAC UNR. lIRV HVAC UNIT
�o 0 60"W/69'l/49"MT AT NRV PIATFORM. .
FIVAC UNT ryVPL W!T
� � � �
' NN✓HVAC PlAiPOP.M. ❑
, � � // � r 9 d'MT °' IXISTIN6 SERVICE DOOR
ry AND FRAME TO REMAIN,
IXi5TM6 9TORPPROM IRAMFS IXISTING GONCREfE FOOTINGS
� AN�GN21NG TO RLMAIN. AND FWNDATIONS. E%15TING E7EQRIG SffRVICE IXISTING
� AND MEfERTO RPMNJN. CONGRETE POOTINGS
. � AND rOUNDATIONS i
� IXISTING DRNE-T11RU TO REMAI4. I
SERNLEN�NWW � IXISTiNGHVACEQUIPMENT �,
TO BE REMOVID. �
. TO REMPIN, I
SIDE EtFVATiON IZEAR ELEVA7fION
� IXISTING BUILDING F�CISTING BUILDING
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NEW HVAC UNR. N'.N HVAG UNR
' �p a 60°W/89'L/48'FtT AT NCW PtATPORM. ��' �
NVAC UNR MVPL UNR
� 7 � � O I
, . � � � � NEW I1VAC PIATPORM. ❑ - ' I
' 9'O"HT
I �' IXI571NG SERVIGE DOOR
AND FRAME TO REMAiN.
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IXISTING STO,QEPROM PRAMES IXISTiNG CANCRFfE POOTINGS �
AND GN21NG TO R�MAIN. ANO fOUNDATIONS. IXISTING E RIC SE4VICE IXISTING !
AND MET:RTO REMAAIV. CONGRETE POOTINGS i
AND rOUNDATION5
IXISTING DWVE-TRRll TO RFMAIN. , i
SERVICE WINDOW - IXISTING MVAC EQUIP'MENT
' TO RETANN,
� TO BE REMOVE�.
i
SIDE ELEVATION . RFAR ELEVAITiON I
DCISTING BUIIAING DCISTING BUILDING
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