276 HIGHLAND AVE - BUILDING INSPECTION (7) City of Salem ware
y
APPLICATION
FOR -
PERMIT TO BUILD ADDITION, MAKE:ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT•ApplicaN to complet "Hems In secWns:R IS III, IV,and IX.
L �r:t<ciciiiiort►_a1�16 �a�WALA 6,-N ��t zow"
LOCATION 1D�
OF BEMEEN Mah'Cf3wn,4-= no AM DR LEn.-s �
BUILDING �
(CROSS ant,
LOT
.. . .. SUgprytgtO,t LOT BLOCK SIZE
IL TYPE AND COST OF BUILDING•All applicants-complete Pants A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOUTTON"USE MOST RECENT USE
1 ❑ Now building RemdenWl
2 ❑ Addition(s madenlei,whIf number of new- 12 ❑ One,family 18-Q.A wwmaK rscrerdbnm .
I housing writs added,9 any,in pan D,13) is ❑ CNICK cow rahwou .
13 ❑ Two or rnae IamM'•EnW number 20 ❑ IrdustrW
3 g) Alteration(See 2 above) - of unit
21 ❑
4 ❑ m Repair replacement 14 ❑..Tmrmis m.w for mold,Or donnneto/Y• 22 Service sta5oe.repair garage..
Enter mrmbeiot units
5 ❑ WreckWQ(M=&Iw ry msid&*K enter number 23 ❑ Hospital wmft cruel
of units in buldbg in Part a 13) 15 ❑ Oerepe _ 24 ❑ Office,bank Pmfsesb-9
8 ❑ MMng(rebcation) is ❑ carport, 25 ❑.PuElp um"
I . 28 ❑ 3d"WNW,olw aducatiorrel
7 ❑ Foradatlon onN 17 ❑ Other-SPecrY 27 ® Staraa.mewcmdie
S.OWNERS1-P 28 ❑ Tenk%lowers
e CR Private(individual.Corporation,nonprofit ❑ Ww,wry
ina6Wnor4 SIC.)
9 ❑ Pudic(Federal,State,a local government - - -
C.COST (Omit cereal Navel.Describe in dent proposed use of buildings,e.g.hood processing dam.
wechine shop,tawdry buYdng at hospital elerrAntary School.Secondary school CDROM
141 Cast d hnprovemem _--'_ _----. i I Sa OD0, perco lal school:'perkbg garage for departmers I . rental office building,o building
at industrial Plard.P use of existing buildhq le being changed.draw proposed
To be installed but not inchded - n��n,
in the above cost 1• L 3-rz tT-4
a. Electrical —.___._.__._.__.__...._._......_.__...__ aC0 I
b. Plumbirg -
C. Heatag,an tondifionnng.—__.-._.___—____
d. Omer(elevator.
11. TOTAL COST OF IMPROVEMENT I SQ t 007` - - .- .. •.• -
IIL SELECTED CHARACTERISTICS OF BUILDING •For new buildings and additions, complete Parts E--L;demolition,
` •` " _ Complete on Parts J&Mall others ski to IV '
3 E: PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATNG FUEL Q TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL 1
3 9p ❑ Masonty twat bea ng) 35 ® Gas 40 ® Public or prints camPaM V� Will there be unlyd at
.31 ® Wood hams 38 ❑ w - 41 ❑ Private(septic tank ale.) - _ cardilenirg7
45 ❑ No
� lIpC1
32 ❑ Structural stem 37 ❑ Electric ib.
ity {O
33 ❑ Reinforced Concrete 38 ❑ Core K TYPE OF WATER SUPPLY- - wig 8wi by an efevatolr
34 ❑ Gtlw•SWAY 39 ❑ over•SW* 42 ® Public or Private company 48 ❑ Yes _ 47 ri NO
43 ❑ Prvale(well cistern) - .
i
J
. DEMOLITION OF STRUCTURES:
ge tea d eoa area, Has AppPoval from Historical Commission been received
°m'"�d°A"'�" 11, d o� for any sfnrcture over fifty(50)years? Yes_ No-
-- ---
�,,.
area,W R...___..._.__..._....._..___._—_ O D'g,�afe Number
P oPF srnesr P swLcesResi coma:
Endosed
THE,FOLLOWING UTILITIES BEEN DISCONNECTED?
e._._.__._...___._----..._...----_....---- aYes No
a..---_._..�_...----- - Electric:
Fur---a. --- —'Seww. _
54, MMW a. DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
ba1"10"` BEFORE A PERMIT CAN BE ISSUED.. ,
IV. COMPLETE THE FOLLOWING:
Historic District? Yes— No `�. (If yes,please.enclose documentation.from.H.•ist.Com.)-
Conservation Area?,.Yes_ : No`✓ (11 yes;please.enclose Order.of Condrdons)
Has Fire Prevention approved and stamped plans or applications? Yes__- No_
Is property located in the S.RA'disWW Yes_ No_
Comply with Zoning? Yes No_ (If no,enclose Board of.Appeal decision)
Is lot grand(athered? Yes_ No_ (If yes,submit documentationld;no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yes_ No—
Is Architectural Access Board approval required? Yes_ No_ (If yes,submit documentation)
Massachusetts State Contractor License# CS OS 2';kl'-7 Salem License#
Home Improvement Contractor # Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
If an extension is necessary,ptease submit
CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings-
V. IDENTIFICATION. To be completed by all applicants
Name MabV address-Number,street cM•and sW ZIP Code TeL Na
1.
L9ssee
Z
°v tom°' ,r LecenedwNM CSo58a3�
3. ►1.YNarAA i Lo. 1
arnded o<
0�9'� S3 SM
Ene�
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his aWiodzed agent and we agree to conform to all 24licable laws of this jurisdiction.
Signature f appli Address a�' Application date
,ip�1�101 i
i
CITY OF S�kLENi, TNL-kSSACHUSETTS
• BLILDLNG DP-PeRTM NT
130 WASHINGTON STREET, 3�FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
ICIJ>BERLEY DRISCOLL
MAYOR THobtAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COAL MI[ONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
,
i In accordance with the sixth edition of the State Building Coda, 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
jf this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
j 111, S 150A.
The debris will be transported by:
MA l-rySTt
(name of hauler)
The debris will be disposed of in
PaA
(name of facility)
3� (fjrApL 51.,
(address of facility) 0-5
signature of permit applicant
-1 larl��
date
dcbri.%IT.dm
05/31/07 15:32 FAX 002/002
CORD CERTIFICATE OF LIABILITY INSURANCE OPID P DA�(Mmnxhy''''''
VISIO-2 05 31 07
PRDDucEa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
AgenCy, IAC. - KOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
50 Prospect Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Waltham 1A 02453 .
Phone: 781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA First Mercury Iris. Co.
INSURER B: Aerr 1. mtoEAatsonel G w 43974
Vision builders Company Trust INSURERC: Hanover Insurance Co. 22292
615Ant Coy Grq Stran
615 COriCOrd Str6Btt INSURER D:
Framingham MA 01702
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL WE TERMS.F)CCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD]CLAIMS.
LTR NS TYPEOFINSURANCE POLICY NUMBER DATE MMRJ bATE(MW5OFfYI LIMITS
GENERAL LIAELRY EACH OCCURRENCE S $1,000,000
A R COMMERCIAL GENERALLIABILTTY TBA 05/27/07 05/27/08 PREMISES eeerentA f $50,O0D
CLAIMS MADE 7XI OCCUR MED EXP("we Pelson) 5$5,000
PERSONAL S ADV INJURY E$1,000,000
GENERALAGGREGATE $$Z 0OO 000
GEN'L AGGREGATE MIT APPLIES PER: PRODLJCTS•COMPIOPAGG S$2,000,000
POLICY Lac Emp ben. $1,000 000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB
C ANYAUTO TED 05/27/07 05/27/08 (Fa2e "U`) 51,000,000
ALL OWNED AUTOS BODILY IWURY
X SCHEDULED AUTOS (Per Person) S
R HIREDAUTOS BODILY INJURY
X NON-OWNED AUTOS (Per acddmQ S /
PROPERTY DAMAGE
S
(Per eecden0
GARAGE LMBILTTY AUTOONLY•EAALCIDEIT S
ANY AUTO OTHER THAN EAACC S
AUTO ONLY; AGO 5
EXDESSIUMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE 5
E
DEDUCTIBLE S
RETENTION S S
WORKERS COMPENSATION AMD TORY LIMITS I I ER
B EMPLOYERS LIABILITY WC 694-13-68 05/27/07 05/27/09 ELEACHAOGIDENT 5500000
ANY PROPRIETORIPARTNERAD(ECU IVE
OFFlCEUMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE 1500000
e LreydLW under EL.DISEASE-POLICY LIMIT S500000
SPECIAL PROVISIONS CHow
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS `s
CERTIFICATE HOLDER CANCELLATION
EVIDENC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 SO SHALL
Evidence of Insurance IMPOSE NO OBLIGATION OR LJABILT OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRSSENTATIVES.
ALITHMUIZED REPRESENTATIVE
ACORD 25(2001108) ®ACORD CORPORATION 1999
DO NOT WRITE BELOW THIS LINE
VL VALIDATION
fOR DEPARTMENT USE ONLY
Building
Permit number use ewouv
Building 19 Fire Gradq
Permit issued
Building / ��� �� Lne LoadYq
Permit Fee a
oauvencr Loa
Certificate of Occupancy a Approved b .
Drain Tile. $
Plan Review Fee $ 4°tq �
TrtLe
NOTES AND Data• (For department use)
t ,
Aj
Se Cr JU
U
p/L N
CU
PERMIT TO BE MAILED TO: ��-
DATE MAILED:
Constriction to be started by. Completed by.
x
A ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SCi E OR PLOT PLAN For Applicant Use
O N