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488 HIGHLAND AVE - BUILDING INSPECTION (5) C� lh � 3,� "� Lf � �j� � � � � �o� ,� The Commonwealth of Massachusetts � Department of Public Safety Massachusetts State Building Code(780 CNIIt) Building Permit Application for any Building other than a One-or Twa '1 Dwelling �� (TI»s Secfion For Official Use Only) Building Permit Number: Date Applied: Buildin fficial: SECTION 1:LOCATION(Please indicate Block#and Lot#for]ocaHons for which a street addres s a le) y �g N��a land c�,.�e . Sa.\-ev,r, m� C' e\\ -rower No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Conshvcfion check here 0 or check all that apply in the two rows below Existing Building❑ RepairiPs{� Alterafion� Additior� Demolition � (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Othei Q24 Specify: e t u i • G Are buIlding plans and/or construcHon documents being supplied as part of this permit application? Yes No ❑ Is an Independent Structural Enginee�rin"g P�eer Review required? Yes ❑ No(�' BriefDescriptionofProposedWork:s7WCLp �D �-� � � �xiS+��nC 0..n� pv�QS wi�h (�Pu �(12,5 Y1Y� ^ U-n ' 0.c)�� '.� . h �'i�r�r� PL4� �1�1��15�P C 3 PT�� Q n�j P�a.S �.B �� 0 Cn t�n C(�0.C�_ SECTION 3:COMPLETE THIS SECTION IF EXISTIIVG BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an ExisHng Building Investigarion 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(indude basement levels)&Area Per Floor(sq.ft.) � Total Area(sq.h.)and Total Height(ft.) � SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightdub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institu6onal I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residenfial R-1❑ R-2❑ R-3❑ R-4❑ S: Storage Sd ❑ S2❑ U: Urility❑ Special Use�and please describe below: Special Use: . � SECTION 6:CONSTRUCTION T'YPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone InformaHon: Sewage Disposal: Trench Permit: Debris Removal: � Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required O or french or specify: Private❑ or indentify Zone: or on site system❑ permit is endosed❑ Railroad right-of-way: Hazazds to Air NavigaHon: 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 Pro erty Owner Ca,MA L�w� �S��,c�ca.�r�e P� Cbox 1 � 3:59� R�lan�zi C�� Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �� oouc\c�.5 `��s1 - 9 ato.� - - Tifle �— Telephone No.(business) Telephone No. (cell) e-maIl address If applicable,the property owner hereby authorizes � �ohn m�c„r��aa� `iR (ica,k}1e. s�. R��ina�m� �au ,y Name Street Address City own State Zip to act on the ro er ownef s behalf,in all matters relaflve to work authorized b this buIldin ermit a licaflon. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin is less than 35,000 cu.fr.of endosed s ace and/or not under Constmction Control then check here O and ski Section 10.1 10.1 Re istered Professional Res onsible for Construcfion Contcol a�1 m�C�., _—_ � �-� �� aas ryNa.,me(Registrant) Tele hone No. e-maIl address Registrarion Number `L� �OX $�5 W@,��cc� � Street Addcess City/Town State Zip Discipline Expirafion Date 102 General Contractor SkuG�ure- C �Su\�-ir, � co (� Company Name Sohn 'Cn`C�'�1'�CUc�dv � �6Bg� U Name of Person Responsible for Constr ction License No. and Type if Applicable �( 9 t3rcz��le �+ . Afl��nc�v,n 'm� Stzeet Address ty�Town State Zip =--�1 -��5-(03�-- Tele hone No. business Tele hone No. cell e-mail address SECTION 11:WORKERS'WMPENSATION INSURANCE AFFIDAVIT M.G.L.c 152.§25C 6 A Workers'Compensafion Insurance Affidavit from the MA Department of Industrial Accidents must be mmpleted and submitted with this application. Failure to provide this affidavit will result in the denial of e' suance of the building permit. Is a si ed Affidavit submitted with this a lication? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT E Item Estimated Costs:(Labor and Materials) Total Consfrucflon Cost(from Item 6)_$ ��,�G � 1.Building $ ' � CjQ� . " 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 $ a5� Q Q d (wntact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I heieby attest under the pains and penalfies of perjury that all of the informafion contained in this application is true and accurate to the best of my knowledge and understanding. � m��i�cudav �s�c�.5�'cuc�i�n '1`�c�:C l�l� -3�K-Co3ay Please rint and sign name Tifle —� Telephone No. Date � �� t�� na� o�y�_y—_ �a 3-i Street Address � ity/Town State Zip Municip Inspector to fill out this secHon upon applicafion approval: IName Date � �jy�j��, Mass'r�.�sucznw-OeYartmt.nt of Public aafriy . lT/ goard ot 9uil�ing ReRufaiion=�?�a StGndzrds Cunsirvt[ion Suprn iaur License: CS-07B8B8 .'�•�� . _, i i„ ,:'.,y� . JpHPi G MCGTLI�IID A ^- la BENIVINCToI+t - QUWCY MA 02I69 , 4 i _ '��' i .��`� ` Expiration J..L.-��'�' 07f1112014 Cwrunis5ioner Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot#for locations for which a street address is not available) �� =� �-c��1��'(�I ae- � ��-Q_�Y�� — �� c� Y-e� No. an� City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No � Gas Shut Off? Yes ❑ No ❑ Provider notifiied and Release obtained? Yes ❑ No ' Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 2 Construction Documents aze 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* Mazk"x"where a licable No. Item Submitted Incom lete Not Re uired 1 Architectural - 2 Foundation 3 Structural 4 Fire Su ression 5 Fue Alarm ma re uire re eaters 6 HVAC 7 Electrical 8 Plumbin include local connections 9 Gas Natural,Pro ane,Medical or other 10 Surve ed Site Plan Utilifles,WeHand,etc. 11 S ecificarions \qrS 12 Structural Peer Review 13 Structural Tests&Ins ections Pro am 14 Fire Protection Narrative Re ort 15 Existin Buildin Surve /InvesH aflon 16 Ener ConservaHon Re ort 17 Architectural Access Review 521 CMR 18 Workers Com ensaflon Insurance 19 Hazardous Material Mifi ation Documenffition 20 Other S ec' �C�, Q 21 Other S ec' 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the tune of application submittal must be identified herein.Work so idenlified must not be commenced until this applicafion has been amended and the proposed construction document amendment has been approved by the authority having jurisdicfion.Work started prior to approval may be subjected to Mqle the original qermit fee. Registered Professional Contact Information 3ol,n `m�C�il� c.u�ua (�l�l-3�s$-�3�y ��$� 'Ntame(Registrant) C ` Te e�ne No. e-mail address Registxation Number �l� 1J�Ol��f, Jl'• �C1��m� Dis ipline E pirahl!onDate Street Address City own State Zip � � � cc� _q7�-� 9R-�a� yG� l Name(Registrant) Telephone No. e-maIl address Registrarion Number �3 �ciX �S�S (.�P.�`s�-�fc1 'C��} (�-3G—I Street Address Ci /Town State Zi Discipline Expirafion Date Name(Registrant) Telephone No. e-maIl address Regisiration Number Street Address Ci /Town State Zi Discipline Expiration Date ' � The Commonwealth ofMassachusetts - Department of Industrial Accidents -• � Office oflnvestigations 600 Washington Street Boston, MA 02I11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeiblv N3IDe (Business/Organization/Individual):�(�(`�Ce, W�� LjI1'1(�O v((�j U�_ Address: �{q CQ�}�£ �-� . City/State/Zip: ( '� 0 ��J Phone #: (p I�] - 1 gO - S 7 �/� Are yau an employer? Chec the appropriate box: Type of project(required): 1.� 1 am a employer with 3 Q 4. � I am a genera] contractor and I employees (full and/or part-time). + have hired the sub-contractors 6. ❑New consvuction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, � Demolition working for me in any capacity. employees and have workers' 9. � Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. � We are a corporation and its 10.❑ Electrica] repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ��,Q p]umbing repairs or additions myself. [No workers' comp. right of exemption per MGL �2.� Roof repairs * insurance required.] t c. ]52, §1(4), and we have no employees. [Noworkers' 13.�Otfier�e�P.CO'M comp. insurance required.] 'My applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowmers who submit this affidavit indicating they aze doing aff work and then hire outside convactors must submit a new affidavit indicating such. �Convactors that check this box must anached an additional sheet showing the name of the sub-wntractors and state whether or not those entities have � employees. If the sub-wnvactors have employees,they must provide their workers'comp.policy number., � I am an emp[oyer that is providing workers'compensation insurance jor my employees. Below is the policy and job site enformation. Ins�rance Company Name�(�(_P Q�Z^�5()��X1 G'e ' Policy #or Self-ins. Lic. #: �O` O��S Expiration Date:_��—�� Job Site Address:� � R I.G�\Qlfl(� ��'P City/State/Zip: ��(y� ��- 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 $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$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerC y under the pains and penalties of perjury that the injormation provided above is true and correct. Si ature: Date: � � J Phone#:��p�1—�� 7 t{ (� Official use only. Do not write in this area, to be completed 6y ciry or town officiaL City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cily/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ANTENNA CONFIGUf�TION 0E�'si�iat°`co_umce rowerr__ P�Posm veRizaN z�c-�eo-o . . 850 Nf1ENNAS (1YP. OF 1 PEIi LTE PCS 850 AWS SECTOR, TOTQ OF 7) TO . . . . rscauce rximnc uncnws �/� �. �a 160*�mL VERIZON ANfENWS r�jI7�11wireless EX6nNC Un[llY EXISnNG CSC ON . 400 FRIBERG PARKWAY 90AR0 CONCRETE PAO PROPOSED VQiIZON RRH2x10-�WS (IYP. OF 1 EXISDNC ✓ERIZON WESTBOROUGM,MA. PER SECTOR, TOTQ OF 1) NOl1N1EU AT RFAR � WIRE(E55 ANIENNA 07581-3936 OF PROPOSED ANfENWI (1YP. OF 6J � (508�3343300 �x x v x r � �� SEE NOTES BELOW: (�O REMAINJ I � � � . PflOPOSm�ERIZON HBX-651]DS-VfM_OODT AWS. . . . � A � PNiENWS (IYP. Oi 1 PER SECfOR. TpTAL OF 3) � . \x ' i0 REPIACE IX6TNC ANfENW�S . .. wob�� ,� ' S�yBorne i � exisnmc . . � � exirnmc vAmec � T.e C fl fl 0 � O I E 5 ✓ERIZON . . . ANIENNA (IYP.J � . 9 EOUIPMENT � � � SHEU£R +\ . ' . � P.O.BOX e]5 WESTFORD,MA 01886 s ' . EMAIL:tlryan@skybomelach.ne� 1 SITE NAME Ex,�r,�� R,�o� � LYNN 3 MA CABLE BRIOGE PROGOSm HYBRID COP% CABLE � � . (ttP. OF 1 PER SECTOR. TOTAL � EX/Sbi✓C WMP OF 3) TO iOLLOW IXISTING �� . � ANTENNA (IYP.J CONSTRUCTION EXHIBITS CONI ROUIING � � \ EXSPING 1]0' \ ❑ � � (ATT/CE RIWER � � \ \ � \ \\ \ \ \ EXISTING FENCEO-M EX/STING D/SH \ COMPOI/NO ANIENNA (]YP.) � 0 17J0&13 FORCONSTF2UCTION � � PROFESSIONAI STAMP � \ EX/SnNC EOUIPMENT \ ' ON CONCREI£PAO � ' � � (1YP.) . . . . . . ' �� . . . . 1�.SH� cxisnNc cnetc . �a� . . BRiDGE(�rP.)� �. � . , . . . . . . . . . . . . �cT PAUL�G� � . . .. . . � . � .. . . � - . . ' ' . . . � - � .. . � . . . � . ' EXISANC ACCE55 � � . . ' ' � " G4TE(IYP.) � .e ' . ��.� . . . . ' . . . . �� . � � � ' DRAWMBV: CAM i CHECKEDBV: PLM � EXST/NG SITE ADDRESS � - � EOUIPMENT �� sHec�a \ � cximNc vicerzoN 488 HIGHLAND AVENUE � EOU/PMENT . � �' cxisnNc Fe,vicea-iN sHE�rER SALEM, MA 01970� COMPoUNO SHEETTIRE: - COMPOUND PLAN & � \"�. . , . .—. . . .—� .� Ex�s�� oE ELEVATION �EL 0�3 A.GL. COMPOUND PLAN �1 5 2.5 5 10 Y0 2 SHEETNUMBER: NPIES' 10 0 5 10 20 b ,. crnvnwcroa m tzxur,aevuecc cxa�ror+ ELEVATION � SGIE: 1'=10'-0' _ . 2. AMENN4 SfCR1R RJ BE MSTKLEO/N �: ,.ezo._o. _ A- 1 � ACCOFPLVCE M11N 10NER A4WUFACR/RER RELI�NMEN61PON5 AND SIRUC7UNAC AN4Ln'/5. 3. Q�NlR.iCIOR TO F/ELO VEMFY AfL EX/S1/NC IH/5 PUN SNEE!/S TO BE USED/N CONJUNCI)ON M'/II/CURREN/SIAUCIURAC lJNCn/5 R£fER(NC[p PRONSm/NSTiY(AIXM� �,anONS�pppqpSEp pfs��y ANO NpnFy SCAIE: . . . ENC/NEfR OF�"D/SCREPi1NC/E5. TW6 PIAN TO SLALE WHEN YRINTED AT HY1i'AND 1DD%SCALING