0488 REAR HIGHLAND AVENUE - BPA-10-869 y e ommonwealth of Massachusetts
Department of Public Safety
{. •r• y \la.achux�tte tit.rtr tltnldin/;lady I780 C\1R)`:a-rnth Edition
•.
City of Salem
Building Permit Application for any BuildinX other than a I-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Inspector:
SECTION 1: LOCATION(Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
/lira.fnn nhl n ']0 - m y r
No.and Street City /Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair❑ AI[eration Addition❑ Demolition O (Please fill out and submit Appendix 1)
Changeof Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents bring supplied as pant of this permit application? Yes No O
Is an Independent Structural Engineering Peer Review raluir
� Yes ❑ No
Brief Description of Proposed Work: i
>Tc 3 (fin 9WIrYrl Lt)ll,�L(S � _
SECT[ON 3:COMPLETE THI5 SECTION IF EXISTING BUILDING UNDERGOING RENO TI VAON,ADDMON,OR
P
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0 r
Existing Use Grriup(s): Proposed Use Group(s)-
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
sECT➢ON 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.)
SECTION 5:USE GROUP(Check as a livable)
A: Assembly A-1 0 A-2r O A-2nc O A-3 ❑ A-4❑ A-5❑ B: Business ❑ N-4O
nal ❑
F: Facto F-1 O F2❑ H: HighHazard H-1❑ H-2 O H-3 S0
1: Institutional 1-1 ❑ 1-2❑ 1-3 O 1-4❑ M: Mercantile❑ R: Residential R-101❑S: Storage S-1 ❑ S-2O U: Utility❑ Special Use❑and (rase
Special Use:
SECTION&CONSTRUCTION TYPE(Check as a livable)
IA O IB ❑ IIAO 1180 IIIAO III80 IV 0 VA ❑ Ve ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details omeach item)
Trench Permit:N A Debris Removal: (j
{ Water S ply: Flood Zone Information: / Sewage Dispos : A french.will nut IN Licensed Di.pus.d Site l
Public❑ C by k if autade Fl.n+d G.ne Pl Indicate mumafvl O nyuired O or trench ur.tvtidc:
I'rrcate❑ or mdunufc Zone:_ ,r nn ate.r.tem O permit t.enclosed❑
j Railroad right-of-way: Hazards to Air Navigation: xL\ I h.e•na t".•nnu..a.m It,...,. Pr.•
\ut .\I+phcablc
I-<Iru.aur a.ohm aup.mt al •roach an-a.• I.thou n•a iric onnl•hdrd.'
.:r l nn.vnt b� 1$uld elldovd❑ + I}a•.❑ ut Xn I� Ye,❑ \o ❑
SECTION 8:CONTENT OF CERTIFICA TE OF OCCUPANCY
1 1..idum.d C.:dc _.._L+•t.ruupi.i: rt pv ni C.m.trutu n: ulcctipant Load per l I....r
(h - ll b I 1 i4 nt t n t t sprinkler >la•cmi�tipulat un.
SECTION 9: PROPERTY OWNER AUTHORIZATION
N, me and Address of Pfoperh,Owner /ley l„..n OA70
G � /nhla nd kz J
Name(I not)
No.and Street Cih'/Town Lip
PAro,)x rh'Utcnneer Contact Inturmaliun {�-
rtll'�Q,{'ICa(/"1 I�IQ tit- &�Km
Title Telephone No.Ibusmrss) Telephone No. (cell) e-mail address
If..tt.plict(+lrnrne. the property owner he e v authunzrs n `� _a I n U It�
� Pa(«[141CfA � 3Y(ji V 1/A M��
24
Name Street Address Cih•/Town Stale Zip
to act on the ,r,,+rrt% owner's behalf, m all ma tiers relative to work authorized by this building per mit a > plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(lf buildin•is ka than 35.uW cu.It-of rneLwd: am and/or not under Construction Control then check here O and ski Section 10.11
10.1 Registered Professional Responsible for Construction Control
NAPI L 0t1 40313
Name(Registrant) u. e-mail address R istration,Number
1 l lPtr)a f rnitYYt f D f . C�St !�rrnnr�QlNP� _ 1Z1_ Za M O)
Street Address' City/Town State Zip Discipline Expirat un Date
10.2 General Contractor
W M L Al Q&
Cu'Sny.Nam ' C C% Q,lbA9
Name a Person Res tnsibl fur Cunstructiun crone No. and Type if licable
Mwr 1(aar� �4-
---_�7 City/Town Stare Zip
S��t+rget Address ,IYlP 1y�n nn Cln G(r(p} (l,(�yVl
Telephone No.(business) Telephone No.(cell) - e-rnail address
SECTION ll:WORKERS'COMPEPfSATiON O SURANCE AFRDAVCI(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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
UC�ts:Item Total Construction Cost(from Item 6)=S �'1. Building Building Permit Fee=Total Construction Cost x_(Insert hem2.Electrical appropriate municipal factor)3.Plumbing 4. Mechanical (HVAU Note:Minimum fee=S (contact municipality)5.Mechanical (Other) Enclose check payable to
6.Ttal Cost (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below. I herebv attest under the pains and penalties of periury that.ell of the information contained in this
applicaton fs true and accurate to the best of my knowledge and under<l.mding.
Gila V) t tt�v(lvnl Pn�ra a fes ►�_, of—ems �.� 4q,
-Or pn„nl .in.d name rifle Telephone N,, Date
N*, (21
t
tit Feet lddress City;To%%n SLne Zip
i
\unicipal Inspector to till out this section upon application approval: - - —
\ame I)a to
_ The Cotmttoltlreatth of*Masatchitscrts
Department of lmlustrial:tcc•idetlts
Office oflnrewl qurions
600IVns'hittgloaStreet
Boston, i11lass. 112111
n•u•1/•.ntas'.c.�a,Jelin
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbcl-s
Applicant Information Please Print l,egihll,
\anlettusio .nre:mirariomhldi,iduat), Nattepashemet Project Pianageatent, Inc.
Address: 32 Beverly Ave. - Suite 1-A
City/state/Zip: Marblehead, i•IA 01945 I,llolteg: 781-727-6516
Are you an employer?Check tie appropriate hox: Type of project(re(juired):
I. I ant an employer with _ 4. 1 atn a general comraclor and 1 6. 1 New construction
employees I full andbr part tints).' have hired the sub-contractors 7. Rvnlodeline
T 1 -.m a sole proprietor or partner- listed on the anached sheet.
ship and hare no emplovices 9'htsc soh-commcmrs hays S. [. Dcnlcrlition
working li r tire in any calmoly. c riplo;ecs:md hint workers' 9. r Buildine addition
INo workers' comp.insurance couip,insurutce-
Z `
required] .. We are it corporation:nut its 10. Electrical repairs or additions
_. 1 :tire a homeowner doing all work officers hate evzrciscd their 11. Plumbing repairs or additions
nwself INo workers' comp. right of exemption pernt \IGL
insurance required] t c. 152.§ 1(4).and we have no 12. 1 Hoof repairs
entplovecs.line worker; 13- Xother Wireless Eou.i.p_
comp.insurance required.] - -
`An)upplicanl Ihal rheela ho♦f1 ma+t al,n fill out the'ernun helm,ehnning ihcir wurhrrs'conpmnvttinn pblicr rnrnnnatinn.
ill onu•o..nrr,u hn 5n1.mil Ih i,a mdaciI indicat tag I hn are 11o111g all„III..a111I then hire•anl,ide eoulrlelu11 mutt suhurit a nee amdoeil indicating anoh.
,Coutnctnn Thal ehmh Ihis lure must suavlt un additional,hmt,bras ing the name or Ihe,nit-coutrtdarn and state a lerdur or not thou entities hare.end Jiluo re,. If
the,111-ctntrartors hate eoieta%tt- the, mu,lJim,ide Weir oare,'cutnP.,tour,nundter. _
t rem rtn enlphiter that is prm•iding h taken'conrliencation inutrnnc•ejbr tm•cvrr/dnr<<ev. nelnu•is ate policy turd joh sire
irjrrnmrion. The Hartford
Insurance Company Name:
0 8 D7ECC 0 7 72 5 Expiration ion Owe: 01/0 4/11
Policy sir Self-ins.Lic."!:__ R . _ _..._ _ .._ 1 __ - --......_._ - -
JobSitcAddress: `1.88R Highland Avenue 4BOS0025A GMS,nc"/ir: Salem,_. K-'s.
Attach a copy of the workers' compensation policy declaration page tsho%vinti the policy number:end expiration (dale).
Failure to secure u„ertue as required under Section 25a of MGL 1.�2 can lead to the imposition of erintinal penalties ol'a line
up to 5l. 00.00 and6or one year imprisonment as well as civil pemdfies in the form of a STOP WORK.ORDPR and a fine of
S2i0.00 a day against violator. Be advised that a copy ol'this statement maybe lorwarded to the Office of Invemigations Uf the
DIA for coverage verification.
1 du herhr/cerpfP-rn der !e ruins surd penahfes of perjure•that the hifornunion provided above is irtte read correct.
Simrnurt*� l f)nar. May 14 , 2010
PriluCaner: obis Nestor phanet.: 781-727-6516
Official rise Drift Des nol write in this arert in he eanlpleted hr eilf or tnlcn official
City or TtoNn. Pernlitllicense th
Issuin;;Aulhorily(circle one):
Minaret of rleath 2. Building Department 3.Cilyrfmsit Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact persum Phone 4:
coRD® CERTIFICATE OF LIABILITY INSURANCE OPID D0c DA 0,111 1 .0
9NANE01 04/13 10
.PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John J Walsh Ins Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P 0 Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem NA 01970-6407
Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE NAIL#
INSURED INSURER A: The Hartford
INSURER B. Landmark Insurance
Nanepashemet Project Management, INSURER c: Citation Insurance Compan 40274
32 Beverly Ave INSURER
Marbleheaa MA 01945
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE°TO THE INSIIR®NAMED ABOVE FORTHE POLICY PERIOD INDIQATED_NOTVITHSTANOING
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-AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR $ TYPEOFIMSURANCE POLICY NUMBER GATE YWD�TI� DATE MlNDO T N LIMBS
GENERAL LIABILITY EACH OCCURRENCE $ $1,000,000
A X GOMMERCIAL GEwERU Luslrry OBSMWQ3098 03/01/10 03/01/11 PREMISES Ea orcarenca s $300,000
CLAIMS MADE FX70CCUR MED EXP(AW am person) S$10,000
PERSONAL B ADV INJURY s $1,000,000
GENERAL AGGREGATE $$2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S$2,000,000
POLICY PROECT- Ll LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANYAUTO (Ea.¢Earn) $ 1,000,000
C X ALL OWNED AUTOS RXQ108 05/21/09 05/21/10 BODILYINIIRY $
SCHEDULED AUTOS (�,W--)
C X HIRED AUTOS RXQ108 05/21/09 05/21/10 BODILY INJURY $
C X NON-OWNED AUTOS RXQ108 05/21/09 05/21/10 (Pera¢MeN)
PROPERTY DAMAGE $
(PeramtleN)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EAACC S
AUTO ONLY: AGO S
EXCESS/UMBRELLA IJASRJTY EACH OCCURRENCE $$5,000,000
A X OCCUR �CLAIMSMOE 08SBAUQ3098 03/01/10 03/01/11 AGGREGATE $$5,000,000 i
$
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION - -
ANDEMPLOYERS'LIABILRY YIN TOW LIMITS I X I ER
A ANY PRORIETORIPARTNDE�D'+ECUTVE❑ OBWECCO7725 01/04/10 01/04/11 E_LEACHACCIDENT $ $1,000,000
OFMCERIMEMBE(Mandatory in NH) EL DISEASE-EA EMPLOYEE $$1,000,000
If
Se under
PECIAL PROVISIONS IRbw EL DISEASE-POLICY LIMIT $ $1,000,000
OTHER
B Professional Liab. LHR712664 03/01/10 03/01/11 Oce/Aggr $214il/$214il
A Installation OSMSR02589 05/26/09 05/26/10 Limit $100 000
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIE EXPIRATION
0001003 DATE TIEREOF,TIEISSUING INSURER WILL ENDEAVORTO MAIL 10 DAYS WRITTEN
NOTICE TO TIRE CERTIFICATE HOLDER NAMED TO TIE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LUUUL TY OF ANY KIND UPON TIE INSURER,ITS AGENTS OR
MetroPCS
285 Billerica Road REPRESENTATIVES.
Chelmsford MA 01824 AUTHORIZED REPRESENTATIVE
David C Bruett
ACORD 25(2009101) O 1988-2009 ACORD CORPORATION. AB rights reserved.
The ACORD name and logo are registered marks of ACORD
�- Yla,s:tchu.ett+- Depanntent of Public',afct
IF &ran!of Buildin--Rr_ulations and Mandanl.
, Construction Supervisor License
License: CS 47636
Restricted to: 00
JOHNJ NESTOR
32 BEVERLY AVE _
MARBLEHEAD, MA 01945
Expiration: 12/612011
/unnni..i"".. Tr:-.`; 108.56