370 HIGHLAND AVE - BUILDING INSPECTION (2) City of Salem Ward--�—
e ,
APPLICATION-
_ . _ FOR:, _s
PERMIT TO BUILD ADDITION, MAKE.ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT APPlleant to corripMt6'aNYterris in sections:414 ti4 N, and IX
1. - .:AT(LOCATION►. �„
LOCATIONn I
OF BETWEEN AND
BUILDING caossslarsn esLOT n L
SUBDMSION LOT BLOCK SIZE
U. TYPE AND COST OF BUILDING -All applicants complete Perts'A-D
A. TYPE OF IMPROVEMENT - D. PROPOSED USE•FOR"DEMOUTIOW USE MOST RECENT USE
1'R New building ReelderlWl Nonresidentlat
2 1:1 Addhion ro,eaioensiIK enter number of new o 12 ❑ One family .. 1B-0 Anrmament racreationel -
housing units added,i any,in pert D, 13) :" /3 ❑ Two d nrorefanntiy•Ender number is 13 cwurll cow religious .
3 ❑ Akeration(Sae 2 aboval - Of unite 20 ❑ tnttnmw
21 ❑ Parking garage
4 Repair re nt Repaplaceme 14 I]..Tmna*d hotel.moth.d dernnicrY- 22 0
Service sWlicn repair garage..
-Enter rwmberd unrls _._::......._.
5 ❑ Wreckn9(d MWwnry resuendal erndr number " Haepiat,WOOL iorW _
of unil8 in building in Pen D. 13) 15 Q•Ciaraga _. ,- 24 OAloek bent,professiorW
S ❑ Moving(relocation) Is Carport 25 Public ui tY
_ - 26 ❑. Sanmllib W.dtw educatlwW .�
7 ❑ Foteedatlonn only - - 17 m Ow•SW* 27 ❑ SloreR msnbanae
a.OWNERSHIP 26 ❑ Tanks,tower
9 Private(Individual corporation,nonprofit 29 ❑ Other-Speciy
inatitrdk n•ate.)
9 ❑ Pudic(Federal.Stele,or local government -
i
i
C.COST (OrnAGeow Nonresidential-Describe in detai pnopoeed uee d buddffm ,e4,food Processig Plain. I
machine shop,wundry buidng at hoapseak elenwerr y schwa,sword school coiege.
_---_—'--- t parochial school r
Puking garage for depanerd store,renal ON"buidrq,once building
10. Coal d inpnrovernwd
_ at industrial piers-M uee of eaiagrg building is being clanged,enter Proposed use.
To be Installed but not included " Alp
l q�
in Me above coat /1p
a Electrical
b. ,Plumbing
a Hewn%air ovbitiorung.________—_._.__
d. Omer(ewvator,etc.).---------
11. TOTAL COST OF IMPROVEMENT Ooo. r
IIL SELECTED CHARACTERISTICS OF BUILDING •For new buildings additions, complete Parts E-L;demolition,
corn to only Parts J&Mall others skip to IV
E PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL, G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL
30, ❑ Masonry lwae bean) < 35 Oats , -. 4 4XPulFC or pnvar company Will PMre.Ee Central air
'* + 31 Wood frame 3Oi � Gil ❑ Pr'nvate lsepac-lack e/°c.) `. .� cordebnig7
P32�Structural steal 37 ❑ Electricity `«� ❑ No
33 ❑ Renrorced concrete 38 ❑ Coal K TYPE OF WATER SUPPLY RYA there by an az eMvaWr_
o9 r,.sR
No
34 ❑ 1x•S 3s pecly ❑ omen-SpeGdy «Ilfiveb oompvtY 47 46 O Ye,
43�PublicPdvats(wail cistern)
J.DarexsrONs M. DEMOLITION OF STRUCTURES:
ere wmbw a s0odm ..-..._.._...._..._..._.__.__..._. _. _
as. roar spuara teat a boor area .. .. _ ,_' HSti Approval from Historical Commission been received
ar r001S'eased W WNW � 'for amt structure over fifty(50)years? Yes_ No_
r, r`
D 'Safe Number
So Tad lend area.as r<__.-- '--.----- -,
k NurreEa of of-srnEEr PAMUNG SPACES Pest Control:
51. Enclosed _..-.-------_.._..-.-...._._.__..__.-_
HAVE THE FOLLOwiNG UTILITIES BEEN DISCONNECTED?
52 Qddoas...._—.._ - - -: .- - Yes No
L REstoo+tuu euaowcs onrur 4f
Sa Encwmd
w. Fur_—_.__.._..__- s, a i f,'. g
y{'54. Numbers. �� DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
badaoonr Parsel ----------- BEFORE PERMIT CAN BE ISSUED. -
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ NOX (If yes,please enclose documentation from_Hist.Com)..
Conservation Area?-.,Yes_ NOX ("Yes:Please enclose Order of Conditional
Has Fire Prevention approved and stamped plans or applications? Yes_ No
Is property located in the S.RA district? Yes— No -
'./ Comply with Zoning? Yes - No_ (If no,enclose Board of.Appeal decision)
Is lot grandfathered? Yea No_ (If yes,submit documentation/if.no,submit Board of Appeal decision)
If new construction,has the proper Routing.S(ipbeen enclosed? Ye&Z No_
Is Architectural Access Board approval required? Yes_ No (If yes,submit documentation)
Massachusetts State Contractor License # 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
ubmit
CONSTRUCTION IS TO BE COMPLETED BY: Man extension is necessary,please in writing to the Inspector of Buildings.
V. IDENTIFICATION • To be completed by all applicants
Name '� _ Mailing address-Number.sbee4 cdY,and sWAs LP Cade TeL Na
no
Owner a
Lessee
2
c7y81 "03-
a -EVA '�+�•
wchded w o
Engineer a ,,
I hereby certily 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 authorized agent a ree to conform to Mi applicaNe laws of this jurisdiction.
Application date
Signature of applicant Address
f1U,�t.�v, y/!� 03632
_
ri _ k Olfioe:
603 627-8995 BOARD OF BUILDING REGULATIONS i
TIMMeEe' ( Residence: License: CONSTRUCTION SUPERVISOR
4 .: (603)778-0895 Number: CS 067481 ? "I
Birtfi_date: 03/1.6/1953 {
{ Expires 03/18/2008 Tr.no: 17&15
t,,
YI acr
r .vt' , g� Restricted 00
`. `"3
p TIMOTRYJ MCCAIN
s y„ 'v`'• ,.^" ��� MORTON j 45 AMESBURY
865.Lori�dondeny Turnpike BUILDINGS KENSINGTON NH 03833
W`Aubum,NH 0 3 032-1 61 6 ��° ' I Commissi
www.morlonbuild1ngs.com
_ Board of Building eulations
One Ashburton P ace, m 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 03/16/1953
Number: CS 067481 Expires: 03/16/2008 Restricted To: 00
TIMOTHY I MCCAIN
45 AMESBURY RD
KENSINGTON, NH 03833
Tr.no: 17815
Keep top for receipt and change of address notification.
DPS-CAI 0 50M-04/05-PC8698
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
" Registration: 122719
Type: Individual
tz�> F ts`f Expiration: 10/9/2006
TIMOTHY J. MCCAIN
TIMOTHY MCCAIN
45 AMESBURY RD. t 1
KENSINGTON, NH 03833
Update Address and return card.Mark reason for change.
Address ❑ Renewal ❑ Employment ❑ Lost Card
DPS-CA1 0 50M-04/04-G101218 -
Office: .'.
TINL MC (603)627-8995
J MANAGER
y r 1 ;: Residence:
y (603)778-0895
s
*BUILDINGS
885 Londonderry Turnpike UUm BUILDINGS
Aubum,NH 03032-1616 www.mortonbuiIdings.com
CITY OF SALEM9. MASSACHUSETTS
T"u4 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD 'FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EXT. 380
FAX: 978-740-9846
CONSTRUCTION CONTROL AFFIDAVIT
Project Number. Date: 07-09-07
Project Title: PULEO REALITY TRUST
Project Location: 376 HIGHLAND AVE. , SALEM, MA. 01970
PULEO REALITY TRUST
Nal,�saf Building:
Scope of Project: CONSTRUCT 60'x12'x12O' MORTON BUILDING
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
ARTHUR w_ ROSE 13t 7 . MASS. REGISTRATION NO. 30734 BEING A REGISTERED
PROFESSIONAL ENGINEER Y
Civil Architectural Structural x Mechanical
77
Electrical Fire Protection Other(specify) PROVIDE SITE •VISITS & REPORTS
ON ERED BUILDING ONLY
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE,.ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
1 FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PE S TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIB ING
AS SPECIFIED IN SECTION 116.2.2. E ROSE _.
_ STRUCTURAL— '+
1. Review of shop drawings, samples and other submittals of the contractor as " 'red&yAeico ion
contract documents as submitted for building permit, and approval for confo f t.
IFS
2. Review and approval of the quality control procedures for all code required con
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix 1.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS T 1 SATIS TOR i
AND READINESS OF THE PROJECT FOR OCCUPANCY.
� • STAT''• ?r
_Z' C0 'biFp'.
Signature/ MySs
SUB C IBED=ANDRN TO BEFORE ME:THIS /(� DAY OF%
My commission Expires:
0o0
CITY OF SALEM, MASSACHUSETTS
s PUBLIC PROPERTY DEPARTMENT
120 WASHING70N STREET, 3RO 'FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EX7. 380
FAX: 978-740-9846
Project Number. Date: 07-09-07
Project Title: PULED REALITY TRUST
Project Location: 376 HIGHLAND AVE, SALEM, MA 01970
Name of Building: PULEO REALITY TRUST
Scope of Project: CONSTRUCT 60'xl2'xl2O' MORTON BUILDING
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
MTCunaT T N C.QRX ru . MASS. REGISTRATION NO. 41121 BEING A REGISTERED
PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY '
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil Architectural Structural X Mechanical
Electrical Fire Protection Other (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT,
NOTE: TO BE PERFORMED BY ARTHUR W. ROSE P.E. ,LLC.
--t—Revie�oRArs ' 9, 581nales andpeFsubn>♦ttakfof the contsactby the rnnntl3irfinn
--eefltfaet-documents-as submitted-for-building-permit,and approval-for conforrnance-to-the-deso*Goasept--
REPORT-Appendix I.
rt-OF-THE-WORK, t-31 ALL-St1BM�0R`T-ASS btP
OFFICIAL SEAL
JUDITH R VEST Signature
lgTAW PUBLIC-STATE OF ILUNOIS
SUBSCRIB / � � ME THIS 16 -� DAY OF � � 2007
V My commission Expires:_11�---
a
CITY OF SALEM? MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHING70N STREET, 3RO 'FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EXT. 380
FAX 978=740-9846
Project Number.
Date: 0 7-09-0 7
Project Title: PULEO REALITY TRUST
Project Location: 376 HIGHLAND AVE, SALEM, MA 01970
Name of Building: PULED REALITY TRUST
Scope of Project: CONSTRUCT 60'x12'x120' MORTON BUILDING
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
M rnuMTr,r . MASS. REGISTRATION NO. 41121 BEING A REGISTERED
PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil Architectural Structural X Mechanical
Electrical Fire Protection Other (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
NOTE: TO BE PERFORMED BY ARTHUR W. ROSE P.E. ,LLC.
--r—whop-dra'Nings;-serrles and etbef sdbmi#tats-0f Etas coratraacior asrequ;red h
—eep#aet-doeanieflts-as.sabrnitted-for-hujidingpermit,-and-approval.for-conformance-to-the-desigpcsnse .
professional
T
6F�hfE-rN6Rtf-t-SHfkL-L—.�it�Bivl ASi` .oTHC—sA F M
pt
OFFICIAL 15
SEAL
JUDITH R VEST Signature
NOTARY PUSUC-STATE OF RUNOIS ,,��( �
SUBSCRIB // '� � ME THIS �� DAY OF �— 2007
C/v�� My commission Expires:
CITY OF SALEMr MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD 'FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EXT. 380
FAX: 978-740-9846
CONSTRUCTION CONTROL AFFIDAVIT
Project Number. Date: 07-09-07
Project Title: PULEO REALITY TRUST
Project Location: 376 HIGHLAND AVE. , SALEM, MA. 01970
Name of-Building: PULEO REALITY TRUST
Scope of Project: CONSTRUCT 60'xl2'xl2O' MORTON BUILDING
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
ARTHUR w_ RngF ' -MASS. REGISTRATION NO, 30734 BEING A REGISTERED
PROFESSIONAL ENGINEER Y
Civil Architectural Structural x Mechanical
Electrical Fire Protection Other(specify) PROVIDE SITE -VISITS & REPORTS
PRE-ENGINEEREDON BUILDING ONLY
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PE f S TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH
APPROVED FOR THE BUILDING PERMIT AND SHALL.BE RESPONSIBL ING
AS SPECIFIED IN SECTION 116.2.2. g ROSE m{
STRUCTURAL-
1. Review of shop drawings, samples and other submittals of the contractor as q red&yA wco ion
contract documents as submitted for building permit, and approval for confo s t.
FFs
2. Review and approval of the quality control procedures for all code required con �!
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix 1.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON CnO�MP ETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS T SATIS TOR
AND READINESS OF THE PROJECT FOR OCCUPANCY. ;. Srgr•s %�
.�
Signature/ = :z 4M�� �.Z
SUB C IBED AND RN TO BEFORE ME THIS JCS DAY O
My commission Expires:
CrrY of SALEm
PUBLIC PROPRERTY
DEPARTNt M
..vim al nt /bA`�L
AM W.%9CW.Jai578tT0`jALiN.fLAA 1L.k11s:.9I�
Tn.wf W)M ljkhcI W4W"
Construeden Debris Disposaf Affidavit
(required fat all denalition and renovadom work)
Is=Onlsnee w ith the sixth edition of the State Building Cods,790 CUR section 111.S
Ochri&and the provisions of NGL a 40.S S*
Building Permit to _ . _ is issued with the condition that the debris resulting}loos
this wort shall be disposed of in a properly licensed wants disposal facility as defined by MOL c
111.S 15OA.
The debris will be transported by:
fhb&-bris will be disposed of in
IL
CITY OF SALEM9 MASSACHUSETTS
® m PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALem, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EXT. 380
FAX: 978-740-9846
CONSTRUCTION CONTROL AFFIDAVIT
Project Number. (/- ( G Date: v` / CJZ01
Project Title:
Project Location:
Name of Building:
Scope of Project:
I .CO DANC�WITH SECTION 116.0 OF THE MASSACHUS ST TE BUIDING CODE, I
w y ylalrt- MASS. REGISTRATION NO. BEING A REGISTERED
PROFESSIONAL HEREBY CERTIFY THAT I HAVE P EPARED OR DIRECTLY
SUPERVISED THE PR ARAT . N OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERN r _
civil , Architectural Structural Mechanical
Electrical Fire Protection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed In
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO TH 8F FORY COMPLETION
PROJECT FOR OCCUPANCY.
Notary Public
cam onwealth of Massachusetts
Commission Expires Sign
- June 25,2010 �,r��ff
FORE ME THIS 7/�7 '
DAY OF
F" 1' - 200�
Nora Public commission Expires:�� DLO C C�
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CERTIFICATE OF OCCUPANCY
LOCATION• 3t70 f/.ra#Z-4R/Z> Vim' DATE ±ILZ/ 07
APPLICANT• ��� �c vs rru�czron�
ASSESSO RS I� !4' /� -P-5—.4 t4 . �a�L rJ� DATE:FRANK K
(93 Washington Street) GYJi1 ril fwt 2 �. ir ° "
CITY CLERK DATE:
CHERYL LAPOINTE
(93 Washington Street) �j, y
PUBLICESERVICES 4� DATE: � 4L/.�
BRUCE THIBODEAU
(120 Washington Street) h Floor o 0
,J N
WATER D I 6 �
ATE:
DOTTIE THIBODEAU Gz --
(120 Washington Street)0 Floor
CROSS CONNECT SUPERVISOR ��
BRIAN THIBODEAU Sp . �l O, s DATE:
(5 Jefferson Avenue)
PLANNING i'✓e.i1LTen✓-vrr DATE: r a�
vAtm-
(120 Washington Street) 3"d Floor
CONSERVATION COMMISSION A�& DATE:
6
(irt �v.n Jn iU
(120 Washington Street) 3 d 00
ELECTRICAL p / / ,7 ATE: 9/y/O
JOHN GIARDI�1
(48 Lafayette Street)
(j-9 FIRE PREVENTION DATE:
ERIN GRIFFIN
(29 Fort Avenue)
HEALTH
JOANNE SCOTT DATE:
(120 Washington S t)4°Floor
BUILDING
THOMAS ST.PIERRE DAB'— -�— /
(120 Washington Street) P Floor
The Conznzomvealt/: of Massac/ursetts
Departnfent of Inrkzstrial Accidents
'd l 1 r t office of Investigations
e = ��; 600 6Vashington Street, 7"' Tloor
"' Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: BuildinglPlumbinWEIectrical Contractors
Applicaninfo t rmation: Please PRINT to ibly _
name: Timothy McCain Morton Buildings Inc
address: 885 Londonderry Tpk.
city Auburn state, NH Zi)I_: 03032
___phone # 603-627-8995___
work site location(full address)-
I am a homeowner performing all work myself. Project Type: x❑ New Coostnlction ❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
® I am an employer providing workers' compensation for my employees working on this job.
cnll1pauy Mantle:
address:
City:
n I1n11C#'
insurance co. ESIS BAP9376314-01
ualicy# _ i
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below t- hn hnr rli
the following workers' compensation polices:
comoany name:
address:
city:
ohnnc#•
insurance co. policy#
comoanv name:
address:
c-ily
Winne#•
insurance co. _ poliev#
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of crintinal penalties of a line up to S1.500.00 and/or
one year;'iniprisountent as well as civil penalties in the form of a STOP WORK ORDER and a rune of$100.00 a day against Ate. I undersin in] that a
copy of this statement n)ey be f � arded to the Office of Investigations of file DIA for coverage verification.
I do hereby certify m er the pains aitd penallies o peryur tnl the 'nfornrntfon pro Tided abase is true mid cnrrecl.
Signature Date
Print name
1� Phone It �Z/'��/f----
official use only do not)mite in this area to be completed by city or town official ';
'.I
l' city or town: permit/license# ❑Building Department ]
❑Licensing Board ..�
❑check if immediate response is required ❑Selectmen's Office
ii
contac[persou: phone#; ❑Othcuh Ueparlmenl
.! (revised Sept,2003)
t .�. .., ._._ ,.. _,... ... .
rDO NOT WRITE BELOW THIS LINE
n
IDATION
FOR DEPARTMENT USE MY
number use crow
g 19 L
issuedg pFee $ �a
ate of Occupancy $ Approved by.ile
Plan Review Fee $
TM-F
NOTES AND Data• (For department use)
t ,
PLO
S t/
p/l rV
CU 17,6S
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by
1
S
VI ZONING PLAN EXAMINERS NOTES,
_ I
.. DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES '
SITE OR PLOT PLAN-For Applicant Use .
t
O N