259 HIGHLAND AVE - BPA-11-354 NEW ROOF & STUCCO RPR V ,
1
The Commonwealth of Massachusetts
/ og
Department of Public Safety
Stale Building Cade(780 CMR)Frernlh Edition
City of Salem
Buildin Permit A lication for an Buildin other than a 1- or 2-Famil Dwellin(This section For Official UeOnly)
itNumber: Date Applied: Budding Inspector:1: LOCATION IPlease indicate Block M and Lot N for locations for which a street address is not available)
igb1and Avpnne calpm MA 01 A70 gUge Ki ng
Citc /Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
It New Construction check here❑or checkall thatapply in the two rows below
g Repair Alteration Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Changeof Occupancy ❑ 1 Other Specify: Exterior remodel
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: T- sta I n ptaw Standit4g +a l + a,—a,
Rpt pair + h ]1 at . 13cj-r 112st311 st13 m �i SS6 and e"I-3 -E14:14q, lfi5t--•"
SECTION 3e COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): A-3 Proposed Use Group(s): A-3 1'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 12 , 6001 1 12 , 600
Total Area(sq.ft.)and Total Height(ft.) r ,
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hierc Hazard H-1 O H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ I-2 ❑ 1-3❑ 1-4❑ M: Mantile❑ 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 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
i Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal:
Public Check d out.ide• Flu,nl Zrm Indicate municipal .\ trench-ty,li not he Liic•n.rd C7i.pusal Sitr
required ur trench or.peatc: , `
' I'ncate❑ or indenulc Zone:_ or nn.,te warm ❑ permit i,enclosed ❑ _
Railroad right-of-way: Hazards to Air Navigation: xl:\ I L�bn. < .•uun,�", n H,r„" ('ri ,r..;
\nt .\pl•licablc� I.}I n,i hoc t.nhm aui+ort oppn,.ich an•a' I. then rct irt.c,unplclyd'
't C„n.rnt to Budd encl„wd ❑ l r. Cl Al,� \2•�❑ Ao ❑
SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY
I�,hu,m ,-ltodr S_�Xt1:l�c(;n n,p,�r. 7-3— ftpe,q C,nntruciiot I A_ tica,C•ant l .,ad her l-I„or ]]�_.____
I h,r. the Budd... :,ml.tut.ot tipnnk.lrr?t.tvm': No —?pei ial?upulauum
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Nameand Addressol Property Owner
Swamscott Realty LLC 600 T.ori ng Ave, GAT FM ma Oi97n
Name(Pnnt) No—and Street lih'/Tosyn Zip
Propvrty 0%,nrr Contact Inform.niun:
Terri Desjardins 978=741-4740 _ terri@centercorpretail . com
Title Telephone No. (business) Telephone No. (cell) e-mal address
If applicable, the property owner herebv.urthonzes
LBK,LLC 822 lexington st . 2nd fl. Waltham Ma 02452
Name Street Address City/Town State Zip
to act un the pro pert% ,%,ner's behalf, in a I I matters re•6uice to work aulhonzed by this buiIdin • permit a p pl ication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
Ilf buildin is lash than 35,000 Co.it.of enclosed space and/or not under Construction Control then check here and akip Section 10.1)
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
LBK LLC
Company Name:
Marc G Rochon CSL 56546 unrestricted
Name of Person Responsible for Construction License No. and Type if Applicable
1 "c)- t 1 e_t - 1 a AmPa'rn; 17 ,Ma 01 91 3
Street Address City/Town State Zip
761.1;93- 0990 617 .645. 1596 mrochon@mastoran.com
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2SC(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? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 66 .000 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical 8 3,500 appropriate mu tcipal factor)=$ .
3. PlumbingS
Note:Minimum fee (contact municipality)
4. Mechanical (HVAC) S
S. Mechanical (Other) S Enclose check payable to
6. Total Cost S 69,500 (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bs entering my name below, I he ebv attest un Irt pansand penaltiesof perjury thatall of the information contained in this
application is trueand accurate t +the best of wledge and understanding.
Marc Contractor 617645 -1596 9 21 010
Ple'),e print .nd :hn name Title Telc 1 e\'o. Uate
_ Ilia Bhrtlett Pla e Amesbury Ma. 0 913
~!fr(t Iddres C itc/Town }tat Lip
Municipal Inspector to fill out this section upon application approval:
amrI
)ate
-70
0
IS CERTIFICATE IS 188UED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE
ERTIFICATE HOLDER.THI8 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED
Y THE POLICIES BELOW.THI8 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
HE ISSUING INSURER 8 AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
MPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the poliay(ies)must be endorsed. If SUBROGATION
8 WAIVED, subject to the terms and conditions of the policy,certain policies may require and endorsement A statement
this certificate dose not confer rl hts to the certificate holder in lieu of such endorsement
PRODUCER
Flagehlp Insurance Agency Inc.
Pc 8=40300
New Bodfard,MA 02744
COMPANIE8 AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY
INSURED
Jmd Inc
635 Wareham Street
Middleboro,MA 0234"000
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE UBTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FOR
THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER
DOCUMENT WITH RESPECT TO WHICH TH18 CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF Sl1CH POLICIES.LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
90
L7R TTBCFKWRNM I POLIOYNUOER I POLIC70FSOrIYe DATE POLICYLVMTIOI DATE
A R&CO TqN
D ENPLOYERe'L W LITY LINTS
E PROPRIETOW
ARTNERINEIOCUTNE I
0 FIMDARE:
NCL 0 E=0 9943007 9/24/2010 9/24/201 t PTATUTORY LIMITS
PTMRR
CwrcpcAPpnwIcMWOpwd Orp.
ACCIDENT S t,000,00
ISEASE POLICY LIMB S 7,000,00
N EMPLOYEE III 1 o0
DESCRIPTION OF OPEMTIO N CL P
CERTIFICATE HOLDER CANCELLATION
MASTORAN CORPORATION 8NOULD ANY OFTNE ABOVE DESCRIBEDPOLICIESBE CANCELLED BEFORE THE
ENP RAT ION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE
822 LEXINGTON ST WNTE THE POLICY PROVISION&.
WALTHAM.MA 02452
AUTHORIZED REPRESENTATIVE