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488 HIGHLAND AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts 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) -, Building Permit Number. Date Applied: Building Official: , nn SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) L1 )� I No.and S ) Ci /Town Zip Code Name of Building(if applicable) lU^/ SECTION 2.PROPOSED WORK f� Edition of MA tate Code used_ If New Construction check here❑or check all that apply in the two rows below t, Existing Building❑ Repair�L I Alteration ❑ 1 Addition❑ 1 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 Review required? Yes ❑ No ❑ Brief Description of Proposed Work: { �C4, i e--t� f 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❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I 4❑ M: Mercantile❑ R: Residential R-1❑ 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 13 IVA ❑ VB O 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❑ 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 buddingSprinkler contain an System?: Special Stipulations: C i 1-e(✓ C�\cn42\ O J Gl OU s- � wJ, 021 9 u SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner G u sf.P_snrt A Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �2s 18 - - 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 permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) building is less than 35,000 cnt.fL 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 ( .rlrryocL, G k �03-q 1�5o -E /Q co.,.stic�k Name(Re trant) Telephone No. e-mail address at c-+-C Registration Number 31�jJf/1Lg�/ ((M''— !(2p-j I V f l-� 0 06 Street Add"rels City/Town State Zip Discipline Expiration Date 10.2 General Contractor 'f-- I A C on 51-,_ Company Name lA >C A & LC 2"c IN cl S 1 C, 1 Name of Ilerson Responsible for Construction License No. and Type if Applicable rs 7) JDtn&-t/ C. SC 1C14 rV-Z, ovio Street Address City/Town State Zip W5_ q 1 & Con sltA-13 oak Can- ej�fc1 el � 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? Yesd No O SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ I 00 ° 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 $ �UU, � (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 best of my knowledge and understanding. Please ptint and sign name Title Telephone No. Date Street Address Ct�Town State Zip Municipal Inspector to fill out this section upon application approval: "D Name Date A�® CERTIFICATE OF LIABILITY INSURANCE 03/2 M/2015 ) 03/25/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER 1-832-476-6000 CONTACT NAME: Ron Risk Services Southwest, Inc. PHONE I FAX AIC No: E MAL 5595 San Felipe, Suite 1500 ADOR & INSURERS AFFORDING COVERAGE NAIC If Houston, TX 77056-3089 INSURER A: GREENWICH INS CO 22322 INSURED INSURER B: XL SPECIALTY INS CO 37885 Clear Channel Outdoor, Inc. INSURER C: C/o 200 East Bases Rd. INSURER D: INSURER E: San Antonio, TX 78209 INSURER F: COVERAGES CERTIFICATE NUMBER: 43346449 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR rypE OF INSURANCE ADDLSUBR POUCYEFF POLICY EXP LTR POLICY NUMBER MM/DDr"M IMWDDDrrfn LIMITS A X COMMERCIAL GENERALLIABIUTY RGD3000528 11/01/14 11/01/15 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I-XI OCCUR DAMAGETORENTED 1,000,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ Excluded PERSONAL S ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYa JEo- �LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY Per accident AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B ANDEMPL COMPENSATION RWR3000S3O / RWD3000529 11/01/14 11/01/15 X STA E ERH A WORKERS COMPENSATION YIN AN OFRCERIMEMBER EXCLUDED? NIA A Y PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT $ I,000,000 ❑ (Mandatory In NH) E.L DISEASE-EA EMPLOYEd$ 1,000,000 If yas,describe under DE SC RIP nON OF OPERATIONS below E.L DISEASE-POLICY UNIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more apace Is required) RE: CLEAR CHANNEL OUTDOOR INC - EVIDENCE OF COVERAGE Workers Compensation is evidenced for employees of the Named Insured Only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Qea�ok�pAe ao�catRwmf 4nc. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Dholden 43346449 CLEARCHANNEL OUTDOOR Date: June 1, 2015 Fax # 781-279-1493 To: Whom it may concern; Rt 107 highland Ave, Salem Ma. Clear Channel Outdoor will be subbing work out to Wayne Cocorochio from T.I.A Construction to rebuild 1 of our billboards located on Rt 107 Highland Ave, Salem MA. The total cost to rebuild this billboard will be $17,000.00 Sincerely: ObId n Cros As istant O tions Manager 70 1 -858-04410 781 438.8880 Tel 279-1493 F. Clear Channel Outdoor ' 89 Maple Street o Stoneham,MA 02180 www.clearchannelautdont.cnm I Office of COosumerAf(s ry g Business Regulation ME IMPROVEMENT CONTRACTOR 1j i egisfration: 9998 Type: Piration -g129FQ3.6, OBA _ !� T.I.A.CONSTRUCTId� WAYNE COCOROCH � 37 SPENCER AVE. 3 J. SAUGUS,MA 01906 �` 4 Undersecretary Ii tic Safety Massachu;etts-Department of Pub Board of Building Regulations and Standards ..Construction Supervisor 7 License: Cgpvjls „FF I WAYNE A COCO it 31 Ssagu NMA 01906 "ris. ru.a Expiration J(..- ll'fit9G 0"3r2017 Commissioner