450 HIGHLAND AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
�n� Department of Public Safety
`�\�1J��1[/� 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)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
o llftl! W�✓�- alp
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 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❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ec'p ify:6d�S
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
r
Brief Description of Proposed Work:
r
11
(�
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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile G✓ 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 O IIA ❑ IIB O IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ -Indicate municipal El trench will not be P
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
I JQn a l s� 8" byre uclrc .�4,2 2�!
r
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
IJa¢•Vaa�+• 5tv�cs 1�Z4 --
iF t�nQ� Telephone No. (business) Telephone No. (cell) -mail ad ess
If applieab�le_,^flffie�prope4ty owner hereby authorizes
YU
Nam Street Address City/Town State Zip
to act on the Pro
�epwner' behalf,in all matters relative to work authorized b this buildingpermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
U 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
10.1 Registered Professional Responsible for Construction Control
c�R7-JIWJI C_ Xio�•cfn. 31s�3
(NI (R"egisp'ant) Telephone No. e-mail ad ress egistration Number
!Pl f rr1 L�f3J0,Ad& ,YA Dora
Street Ad City own S� Zip Discipline xpir�atioonn Date
10.2 General Contractor
It1N&AM0A c43,6n=l2c>ynAA%j, �
Company Name
LAXOL-t- & 04W
ame'ol Person Responsible for Construction License No. and Type if Applicable
-41
Street Ad essCity/Town State Zip
1QC1�ytfl \WAO@ YIad&OA4- G✓i--
Telephone No. business Telephone No. cell v` e-maiWdcYress
SECTION 11:WORKERS'COMPFNSATION 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 O No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$315,���
1.Building $30 q&4 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 $ 25 l n`-t!i (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
app atio is true nd accurate to the best of my knowledge and understanding.
Please rmt and sign nar itl Telephone No. Date
Street Address City/Town State Zip
/
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF &UX. . NViSSACHL'SETTS
BL•IIDLNG DEPARTSI&NT
• e 0• 120 WASHINGTON STREET,Sao FLOOR
�aao-er TEL (978)745-9595
FAX(978) 740-9846
KINiBFRI FY DRISCOLL
MAYOR DIRECTOR
ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUtIDLNG COWMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeibly
Name(Busim-ssiOrganizatioNlndividual):IVW� YfYYLJ A,6 4W 4 fsa GCS
AddressA C,)JWAN _ eaLk
City/State/Zip:8iQLWW2..1_L MBA Phone #:(,tM)l/6 1-TV0`i
Are you an employer?Check the appropriate box: Type of project(required):
1.Wom a employer with lol _ 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet.: Z ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13 [a'bther
comp. insurance required.]
Any applicant that clucks box#1 must also rill out the section below showing their worker'compensation policy information.
*1 tomcuwnen who submit this affidavit indicating they am doing all work and then hire outside contractors most summit a new,amdavit indicating such.
:Contractors that chock this box most anached an additional sheet showing the name of the sub•comracton and their workers'comp,policy interrrtaries.
I urn an employer that is providing workers'compensation insurance far my employees. Below Is rho pollcy and fob site
information. /1
Insurance Company Name.�a _� I.� �� � ,S I.13•
Policy#or Self--ins.//Liee.^.#:R-Qf/..3--1(3(I03nn ..--__ __ Expiration Date: �I qz 1 ZOt 3_
Job SiteAddruss'af �07�]L lA.t3C/k!�L City/State/Zipis/.Oa�.,Mti' m47o
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certyy under the pains and penalties of perJury that the information provided above is true and correct.
Date: 7 ] o-1.0
Lf31-S)(a�s1'`I`?(0`1
Official use only. Do not write in this area,to be completed by city or town oJfieiuL
City or Town: PermitfLicense#
Issuing Aulhorily(circle tine):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person Phone#:
T
CITY OF S��I.E.tiI, l�'L35S.'�CHLSETTS
&'ILDING DEPARTMENT
` ' • 120 WASFIINGCoN STREET,31D FLoOR
\ TEL (978) 745-9595
FAx(978) 740-9846
KIJIBERI.EY DRISCOLL T HOKI S ST.PIFARB
MAYOR DIRECTOR OF puBLIC PROPERTY/BL'1T.DIIVG CONLMUSSIONER
CONSTRUCTION CONTROL DOCUMENT
Project Title; Wk"kMt"&W Date: 1hidull,
Project Location:
Scope of Project: �BMd� ' ,fA.'rw '^�eri"°-r]oy 't^ f��.rt-VWk a elmr( w its.
&s d •M-ar"_ui &&.r d/ln,L ¢I+/mlt idb UpA*'r' /Qn TW
In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code:
I " n (��� � ��b( Mass.Registration Number 3 I 1; 71
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
[v]/Entire Project ( ] Architectural ( ] Structural [ ] Mechanical
( ] Fite Protection [ ] Electrical [ ] 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.
Furthermore,I understand and AGREE 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 by 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 the building permit,and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine,in general,if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official,a pr art together with pertinent
comments. Upon completion of the work,I shall submit to the buildin port as to the
satisfactory completion and readiness of the project for ocdupancy. Adr�y
Signature and Seal of registered professional: W31M
strtaFW
;pi�� Cle— Yes. J
OF MhSS�
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural ✓
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Surve /Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the origiiwl permit
fee.
Registered Professional Contact Information
��7 CSG.sAIDU .C 315"7
/'Y - Registration Number
ame(Registrant) Telephone No. e-mail a dress
Street Address ` City own St to Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address - Registration Number
Street Address City/Town State Zi Discipline Expiration Date
CITY OF S.0 ENI, TNLkSSACHUSETTS
BUILDING DEPARTMENT
P• 130 WASHLNGTON STREET, 3'0 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
1lM3ERL.EY DRISCOLL
MAYOR T HoNw ST.PIERRI3
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONL\MIONER
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 111.5
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 f hauler)
The debris will be disposed of in :
Wl o 4nt nor✓ .�^—
(name of cility)
(addre of facility)
\ A0.Xd��lF'1Qt.E�
7VJ signature of permit applicant
date
dcbriulEd4f
Ell 93 M11
41 Dogwood Road
Asheville, NC 28806
Julie Pratt
Project Administrator
jprattP,naroofmg.corn
800-551-5602 ex. 125
Direct: 828-348-2225
Fax:828-687-1230
Letter of Transmittal
Date: August 10, 2012
To: City of Salem
Attn: Building Department
130 Washington Street
Salem, MA 01970
RE: Wal-Mart re-roof permit
VIA:
Hand Delivered: Emailed: Mail: Overnight: X
Quantity: Date: Description:
1 Building permit application
1 Appendix B
1 Construction Debris form
1 Workman's Comp form
1 Construction Control Doc
2 Sets of Plans
I Permit fee-$6,121.00
REMARKS
Thank you for your time reviewing our project. Please let me know if there is anything else you may need in order to permit this
Project.
Signature: Julie Pratt -
■■fl
Corporate Office: 41.Dogwood Road •Asheville, NC 28806 800-551-5602 0 828-687-7767 • Facsimile: 828-687-1230