400 HIGHLAND AVE - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Department of Public Safety
'Vc+•• \la»achlUettS State Building Crude(78'0 CMR)Seventh Edition,
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot M for locations for which a street address is not available)
No.and Street City /Town Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
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 Re vie re. iced? Yes ❑ No ❑
Brief Descn lion of Pnapused Work: t `& L//yj��: a � 7,7
_ r
SECTION 3: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): Proposed Use Group(s): p
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTTON 5: USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ ,1-12❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑_.1-4 ❑" 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 ❑ 110 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details 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 ❑
va to ❑ ur indentih Zone:_ ,r on site sv.tem ❑ required ❑or trench or.pecify:
permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air.Navigation: \I:\ Ili>h,ric tt,,ir, l'w.•..;
\,d ,\pplic,able ❑ I.Structure acnhin .airport approach urea' 1+theii review cona),Ieted'
„rY ,oa'cIII to Build cnClo.od ❑ Yv, ❑ ur.\o ❑ 1'es ❑ \n ❑
SECTIO N.8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: C.e(�rnup(a: fv,)e ul Co rot ruCtaun:
. Ocai pant Lund per I:luor:
)no, the building contain ao Sprinkler Spacm': tipeci,al Stipulatiuns�
-TO �z�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Na e and t idres, of Properly Owner Yc'S� �/
� ��'l
Name (1'rint)
No. and Street City/Town Lip
I'nr rerty lhvner Contact Information: , C
Title Tel n ephoe:No. (business) Telephone No. (cell) e-mail address
If applicable, thq property owner herebv authorizes
Name Street Address City/Town Slate Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin 6 iermit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,000 cu. It.of endoscd<race and/ur nut under Construction Control then check here O and kip Section I0.1)
10.1 Registered 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
C rpany
ame 0� e .ory(tespunsibl or ep uctiun License No. and Type if icable
Str et Ad ress Qty/Town State Zip
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 22092 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note:Minimum f too
$(contact municipality)
4. Mechanical (HVAC) $Mechanical (Other) $ Enclose check payable
6.Total Cost $ _�'L: (contact municipality)and write c eck 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 best of my knowledge and understanding.
Please print and >lgn mime Title Telephone 'o. Jale
�trcet :\�idrecs Cite/To%yn Mate LiF
Municipal Inspector to fill out this section upon application approval: 1
\ame ( ate
it CITY OF &U.&M. NAkSSACHUSETTS
BUILDING DEPARTN11UNT
120 WASHINGTON STREET, Ya FLOOR
T L (978) 745-959S
FAX(978) 740-9846
KINIggR) FY DRlSCOLL
MAYORTHomts ST.Pmm
DIRECTOR OFPLBLICPROPERTY/BU DLNGCOMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Antilicant Information Pl Print e
Vatna (OusittesrOgatsitatiorolnthvttltral):
Address: �' _ !
City/Statezip: &47n7 Phone 2, 7 41-'5 -7Xie
Are you as employer?Cheek thtyappropriate box: Type of project(required):
1.❑ I am a employer with 1/ 4. Q I am a general contractor and 1
employeest-(full and/or par imc).e have hired the sub-cauracmn 6. Q New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet : 7. Q Remodeling
;hip and have no cmploycm These sub-contractors have a. Q Demolition
working for me in any capacity. workers'comp.ingorence. 9. ❑Building addition
(No workers'comp insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
rcquired.l officers have exercised their
3.❑ I am a homeowner doing all work right of cxemprion per MOL I I.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.41M.and we have no 12.0 Roof repairs
insurance required.)t employees.INo workers' 13.Q Other,
comp. insurancerequired.j
•Any applicant mat dMirs bra or must able rag out iw section below showins their workm'cpnionay(on policy infutnatloa
'I henaawre s who stdtnit this aeldsvg indicating they are doing all Mork and thin him ousidt ceatremore must euhnit a new a111t6vi1 indiced it suck
=f.mtr "M that cheek this hate mud attached an additiord shot showing tw tome of da sub-sao uegore and their wwbss'comp.policy infrxnauoo.
l am as employer that Is providlnR workers'rompensadoo lnsarnmee for my emPlayem Be%w/s the poly atrif]"slta
information.
insurance Company Name:—
Policy Nor Self-ins. Lic. X: Expiration Date:
Job Sire Address: City/StatdZip:
,littack a copy of the workers'compensation policy declaration page(showing the pocky number and expiration date).
Failure to secure coverage as required under Scction 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S 1;500.00 and/or one-year imprisonment'as wall as civil penalties in the form of a STOP WORK ORDER and a free
of up to 5250.00 a day against the violator. lie advi.sd that a copy of this statement maybe forwarded to the Office of
Ira cst igal iune oft Ila DIA for insurance coverage verification
/det hereby erred y mrsder tha pains and pentshlr of perjury that the information provided above is true and"rreca
aD
�� •, t tr oat : a.2
Phan A 7
iOJfeiel mse wily. no not write in rhii area,to be cuntpleted by Miry or town ajjleialt
I
City or ruwn: __ PcrmiUl.lccnre X
--... - —
Issuing Aulhurily (circle one): - j
I. ltwrd of Ilralth 2. Auilding Department J.C'itylfown Clerk J. Elecrrical Inspector 5. Plumbing Intpector
6. Other
Gtolact Person: _ -_. _.. Phone X:
1
CITY OF SALE'M
.` i PUBLIC PROPRERTY
DEPARTMENT
M 11 i tll 120 WAS tl.\GI'oNSlN LET • S.\I I'\I, tif.N5:\l'.I It it-.I-ii
TLI:978-745-9i95 ♦ F\X:978-74C-9846
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 11 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(flame of hau r)
The
/debris
�will be disposed of in
/ tt'J4_S'
(flame of facility) /
(address of facility)
signature epermit applicant
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