300 HIGHLAND AVE - BUILDING INSPECTION (4) t
The Commonwealth of Massachusetts
V
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
f1 Building Permit Number: Date Applied: Budding Official:
l`�Ii!x SECTION 1:LOCATION(Please indicate Black#and Lot#for locations for which a street address is not available)
AA -�16)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used ^r If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Revie re uired? r� Yes ❑ No �
Brief Description of Proposed Work: ��
e 4 , dais
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4: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 as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use, -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ BB ❑ IIIA ❑ 111130 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood ZyInformation: Sewage Disposal:
Trench Permit: Debris Removal:
Public A trench will not be Licensed Disposal Site❑
Check if ou Zone❑ Indicate municipal❑
required❑or trench or specify:
Private❑ or inden[if or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: N4 r.\
Not Applicable❑ Struchue within airport approach area? Is their review completed?
or Consent to Build enclosed Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY -
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations: -
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nume and Acidressnnof Property Owner / p
Name(Print) No.and Stredt City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
I plicable, the property owner hereby authorizes
�'� o/9a
Nam Street Address tty/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1Registered Professional Responsible for Construction-Control
10 UdIkt-e . ti "yA0?s—/
'Iqanne egistr �� Telephone No. e-mail address Registration Number
91
Street Address YLICity/Town State Zip Discipline Expiration Date
10.2 General Contractor
v
C , any une
/03�02 �
Na/me of f7 /
PPe�erson R ponssible for Construction / License No. and Type if Applicable
53
Street Address X/Town State Zip
-6�? �- 5M4 7�-&-may
"Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS CONIIIENSA UON INSURANCE AFFIDAVIT M.G.L.-C.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed anal
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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Budding Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici ity)
5. Mechanical Other $ Enclose check payable to tt
6.Total Cos[ $ e (contact municipality)and write check number ier
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enteri y name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
Zrat
applica is tr and ao the best of my knowledge and understanding.
`/�r� I ire/cYdit m1-�-�
n e r' d sign r me Title Telephone No. Date
L vt�y yjj�
Street Address Gty/Town n' State Zip t
Municipal Inspector to fill out this section upon application approval: Gt� J
Name Date
a' CITY OF SALEM
PUBLIC PROPRERTY
*"- DEPARTMENT
.�\u::s:rr anfu:uu
vl\sim
I!:WAvnI\G I U\$I IELI'a SAUt.M,MASSALI II it I IN J197'�
1'1,1; 08- IS•1575 a 1'.\x. 9711•74112-9146
Workers' Compensation Insurunce :%flidavit: Builders/Cuntracturs/Electricians/Plumbers
1 ►licant Information Please Print Le ihl
Nametlluul cvs,)rgamratin vinJtvuluall: OUn/ ✓G
ddre.is:
Ciry,Stalc:%ip! L-IIAI t/ /Y/� �l/�d� Phone 0: `2ifl
IAre\o an emptoyor.0 Check th pproprlate box: 'Type of project(required):
I. 1 ;tut a employer wish 4. ❑ 1 :fill a general contractor and 1 ft, New construction
cnlpluyccs(full Jnd/ur pan-time).• have hired the sub•coniracturs
2.0 I ant a sole proprietor or partner- listed on the anachied sheet. 7• ❑ Remodeling
ship and have no einployvas These sub-contractors have S. 0 Demolition
harking for me in any capucity. workers'comp. insurance. - __9._D.DwWing addition ---- ---
--- I No workers"cuing. fiinsurance 5:' We are a cnr(rorsnon and its
required.) ollicers have exercised their 10.0 Electrical repairs or additions
3.0 1 ant a homeowner doing all work right of exemption per IvIGL I LE] Plumbing repairs or additions
myself. (No workers cutup. c. 132,¢I(4),and we have no 12.0 Rutufrepairs
insurance required.) t employees.(No workers' 13,0 Other
comp. insurance required.)
i Any.q'pLciol that chucks bas ill musi:dw fill out,he w0lau Wow dwwin#their wurkcxi cumponsatiws lxilicy iI&I'mulk"
I fumuuwnan who albmit this omdavii indicalins Ihuy its Join#all work and then Ain wlside courneturs Phil,.uhnlil a nsw at'fidavil indi",n#vlck.
-C,ati tor,Ohm chaxk Ohio box mum anxhod an addi,ional..nano Jluwin#nil name of Ins Nli eemra to6 and then wurkon'coiny,ptd,cy mirnmanun.
/tun fin avup(oyrr tout lr pruvidlnX ivurknl'cuinprnrnfion intanmeo jot ory emp/uyrrr. Br/uw/r the pu/fay ond/ab.site,
iarjurnrutiva ry
InsurmlccC'umpauy Vmne:,Y//r ('..jiJjl��rq-cast �_Q ._._-,---- 2//¢ ler.r
Volicy #fir ScIr-ins. Liic.n: _ IK—In//rJyA_ . __ Expiration Date:Job Jlle-tllllrLaM; cityrstate/Zip:��}/Ps�
Attach a copy of ilia workers'cumpcnsatiun policy declarullon puke(showing the policy ntunber and expiration date).
Failure to secure coverage as required under Scctiun 25A ui'.%IGL c. 152 eau lead to the iinposition of criminal penalties of a
tine up W S 1.51110.00 and/or one-year imprisonment.Js well as civil penalties in the liann of a STOP WORK ORDER-and a fine
orup to S250.00 a Jay against the violator, Ile advised that a copy of this stutcmcnt may be 1'urwarded to the Ullice uC
111% ul the MA lbr Idmitarce coverage \ei',hGation.
/du hereby tar j uirJe be pain and Boulder ujperfrrry that t/rr injurino(lon provided obore is true our/correct
1n•:L I",
U/jkiul here uuly. Do not wrier in rhic orco, to be twnplefrd by city fir fmvn o//icial
l
(.'itr or 1'111rnt Pcrinit/License of
Issuing Authority(circle ofic):
I. Iluard of llcalth 2. Iluddiu{ ncpartnicnl .1. Cilif/ToMo Clerk J. Electrical Inspector 5, Plumbing lospector I
h. Oehvr
l]nuael 1'cnun: - . . Phone 1:
Information and Instructions
i
%fassachusClU General Laws chapter 152 requires all enlplayers to provide workers' conipen5ah0n for their elllployces.
plIrsuaro to This statute,an rmpluree is defiled as"...every person in the service of another under any comract of hire.
spins or implied, oral of written."
.fin ernploper is defined as"an individual,partnership,association.eorporesun ti other legal entity,or any two r t more
d the Gxegoing engaged in a Joint enterprise, and including the legal teprosentatives of a deceased employer,ur the
rccervcr or trustee ul'an individual, pwmership,assoelalioa or other legal entity,employing employees. HOwcvcr the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of this
dwelling house of another who employs persons to do maintenance,construction of repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employee"
MGL chapter 152. ¢25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commooweulth for any
applicant"Ito has not produced acceptable evidence of compliance with the insurance coverage required:'
kddltiunully. MGL chupter 152. 325C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance ul'public work until acceptable evidence ofcumpliunce with the insurance
requirements of this chapter have been presented to the contracting authority."
AppliApplicants
antout-the.workers' affidavit completely,by checking the boxes that apply to your situation and if
pie-- — — necexsary,supply subcontractors)name(a),uthlress(es) wd phone number(s)-along with-fhair_certificrte(a)of __._ .
insurance. Limited Liability Companies(LLCworke Limited
campensationility ainsurance If an)LLC or LLP does have with no employees er than the
members or partners,are not required to carry
uired Be advised that this affidavit may be submitted to the Department of Indus tri
employees,a policy is req al
ge. Also be sure to alga and date the uffldavit The afffdavit should
:accidents for confirmation of insurance covera
he returned to the city or town that the application
Industrial Accidents. Should you have any y ofm or regarding the law the permit or license
if your are required to obtain ng requested,not tut of
workers
compensation policy,please call the Deportment at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rowa Omclats
avit is complete and printed legibly. The Department has provided u space ut the bottom
Please he sure that the affid
of die affidavit for you to till out in the event the OlfiCe of investigations has to contact you regarding the applicant.
Please be sure to fill in the pertllt/llcellse nWmber which will be used as a reference (lumber. In addition,an applicant
hat mwt submit multiple pennin'liceu se applications in any given year,need only submit one affidavit indicating current
Site Address"the applicant should write"all locations in (city or
policy information(if necessary) and under"Job
town)."A copy of the uffdavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner at citizen is obtaining a license or permit not related to any business or commercial venture
(ie, a dug license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit.
I he r Jliice tit investigations would like to drank you in advance fur your cooperation and shuuld you have any questions,
please du nut hesitate to give us a call.
The Dcparuncnt's address, telephone and fax number:
The Cortunonwealth of Massachusetts
Department of Industrial Accident
Otltee of Investigations
600 Washington Street
Boston, MA 02111
'rel. N 617-727-4900 ext 406 or I-877-MASSAFE
Fax p 617-727.7749
It:,.ucd 5.20.65 www.m=.gov/dia
CITY OF S.U.&M. NL-kss.A cHUSETFS
• BUIWIIING DEPARTMONT
' 130 WASHIINGTON STREET, 3iD FLOOR
ILL (978) 745-9595
FAX(978) 740-9846
Kl.%(BFar FY DRISCOLL
MAYOR IHos(AS ST.P>iF1tRs
DIRECTOR OF PUBLIC PROPERTY/BUMOLNG CONNISSIOV ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris 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 be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
tgnature permit applicant
date
dcbnvl(Ja
�la.,achu,etts - Ucpa�lment of Public Satetv
Board of Building Rc_ul:Uions and.5t:mdurds. .
Construction Supervisor License
License: CS 103422 s
Restricted lo:, 00 .,;,-.#,� - 1
DOUGLAS YOUNG
53 BRIAR HILL DRIVE
LYNN, MA 01902 L 1 A.
Expiration:_31152013 Y
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HOME IMPROVEMENT CONTRACTOR P' "N
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YOUNG C.ONSTR d 1..t Y', '$ *•.
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Young Construction
53 Briar Hill Dr.
Lynn MA 01902
781-632-8594
CS Lic # 103422 HIC Lic # 290751
Proposal
A. J. Auto Sales
300 Highland Avenue
Salem Ma 01970
5/10/2011
Sprint office windows
1) Remove existing double windows at front right of building
2) .Frame opening for 10' x 63" glass window. (owner supplied)
3) Finish inside and out. Outside will be brick at left and right of window
as discussed. Bottom will have a wooden sill wrapped in aluminum.
Top will be siding.
4) Install new window frame at right side of sprint store as discussed.
Window will be approximately 6' x 63" as discussed
Notes: Exact window sizes will be finalized when windows are ordered by
owner. Price includes permit, labor, materials and trash removal. Owner will
supply window glass and glass installation
Total price: $1,850.00
Builder date
Owner date