331-333 HIGHLAND AVE - BUILDING INSPECTION n
The Commonwealth of Massachusetts '
# Department of Public Safety
-Massachusetts State Building Code(780 CMR)
Building PPation for any g Permit Application Building other than a One or Tw •o-Fa y.Dwe •ng
'(This:Section Fbr,-Official Use.Onl
Building Permit Number: . " Date Applied ` " " •`'• flding Of tali""
SECTION I:.LOCATION(Please indicate Brock.*and Lot:#"for locafi nsfqi_vrAcha&eeLaddress is not, ailable) '
3 ..Piyn 0/9 ?o
No.and Street City/Town Zip Code Name of Bu' ding(if applicable)
.. ,:.
•,.�,'�'BSECTION"2:PROPOSED;WORK Edition of MA State Code used 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 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering P r view required? Yes ❑ No ❑
Brief Description of Proposed Work:/ /
c S
SECTION 3:I:COMPLETE.THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,,-ADDITION,OR
,CHANGE IN USE OCCUPANCY—�
Check-he're'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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential, R-10 R-2❑ R-3❑ R-4❑
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 ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑
SECTION 7:SITE INFORMATION-(refer to 780 CMR 111.0 for detail§'on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure 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:
g ' • ^ ;,` : _ . PROPERTY.-SECTION
Name id Address of Proper wner
� p _ %ems w-?33
Name(Print) No.and Street ty/Town Zip
Property Owner Contact Information: r 4 S ` C
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building ermit application.
•-i .SECTION 10--CONSTRUCTION CONTROL(Please fill out Appendix 2) PN� ,+
If buddin=�s less than 35,000 cu.'ft.of enclosed'' acc uidjor not wider ConsteuctioniControl the`n,rheektiere�O aiid ski' Secbon 10.1
10A Registered Professional-Re9ponsible for'Constiuction Control:..
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 GenerSk'Contractor{ ,.<, :r",. m .
4y'
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:'WORKEP.S'CONIPENSATION INSURANCE;AFFIWWIT M:G.L.c.152: 25C 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❑ No ❑
-% , '-•'� ,� ' . SECTION IE:.CONSTRUCTION COSTS AND PERMIT.FEE .,,'
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $ -
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
- SECTION 13:SIGNATURE OF BUILDING'PERMIT APPLICANT - - _
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the bes of my knowledge and understand' g.
Q � n 92� 7�l / ? ") a M13
t t t
Please prii�and sign name tle Telephone No. Date
2
Street Address City/Town State Zip
Municipal Inspector to fill out this, ection upon application approval
— Name= Date;`
CITY OF S. Y.Nf
i PUBLIC PROPERTY
DEPARTMENT
luf1>4�Y ti'w'vw� I
vn►cU I i�ovuw.�+a.lna+rr�u+a�t�o�owsrmon�o
:RP�'i0V
Made, "I
Date 7 3
job Loeadce 3 3 l -3 3 3 'c aaK t o
ldvp—
Home Ownar Address
Home Owner Telephone
Pmaent Mania/Address-�
The current exemption of'Womeownere was extended to include owner-occupied
dwellings of me Units or few and to allow such homeow a m to engage an individual for
him who.does not possess a liemse provided that the owner acts as supeevism.
DENNITION OF HOMEOWNER
Persons) who owns a parcel of land on which hotsho resides or intends to reside, on
wWcb them is, or is intended to bel, a one or two Armily dwelling attached or detached
.structures accessory to such use and/or farm strueturea. A persoa who conimmW more
than one home in a two year period shall not be considered a homeowner. Such
"homeownse shall submit to the Building OQleial,on a form acceptable to the Building
Official, that halshe be responsible for all such wort performed under the Building
Permit
The undersigned "homeownce assumes responsibility for compliance with the State
Building Code and other applicable by6laws and regulations.
The undersigned "home ownce certifies that helshe understands the City of Salem
Building Department minimum impaction procedures and requirements and that hevshe
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATLRE �(.tLIU
s^
.kPPROVAL OF SU/LDNG CiSPECTOR
See other tide for $rate code