9 HIGHLAND ST - BUILDING INSPECTION (3) fhe C utnmonwrrhh of Mossachusrtts
Board
o113uildtng Rrgulr tons:,aritl standards. CITY
MassachusrRs Stau Budding Cafe 738 GMR 7 edition
RevisedJunsmirr
OF SALEM
nuilding Permit Appltcahoq To Consti ul Repaq Renovate'O Demolish a 1. 'INAY
Une-ur TiwrFrm/ly Dwe!%ing.
' 0 7bit Section Fa Official Use
Building Permit Number, - Date Applied.
Signature:
RuildfnkCommdsiarcr/Impretauf.8wtdmgs-; fhte .
`SECTION 1:SITUIRFORMATION:
1 I.1 Property Addreiis := 1 I Assentors Map&Pared Nam tbe",
_ ( I.la Is this an ed street° es nog'- Map Numbir Pagel Nwnber m
11—+ 1.3 Zoolag lafor+batlos: 1 0 Propnty Dlateaalou. '=:
m
Luniog DiftriA Proposed:Use =Lot Aim(s, - Fruntaic(R)
I.s:Bugdlo�"SetbaehalD) ,�„,_ �;m
FraaYa:i/- - SnkiYards Rear YW`::' _ .: .
Required _ ProvidedRsS�u,ed ,, - i, i
1.6 Water Supply:(MA.L c.44.§SA) 17,Flood Zosto lnfora adco IJ Sewage DbporN Symem:
laar:` :thgide FltiodZona7 -
Public O Privme O skeposal system O.
/- SBCIiON7 iPROPER7Yin
OWNERSHIW
it Owaerr of t CC
Nana:IPriM) Addmu•fa
SLW
t ,
Tilephae
36C'[ION JeD_ RIPTION OR PROPOSBb V1+ORKr(ebedc W M�t, ppty)
New Constitution O 8xo 4 Building O, Owner<l)ccupted O "Repurs(s).O; Alteration(sj Addttton.,G
Demofidon O Acees�ryBldg.O Numbaofllmts ` Odra OSpeeiry -
Brief Description of Work=:
AA
SECTION O..F.S'1'IMATBD::CONSTRUCTION C037'9
Ealimmed Cosa:
Item 011klal'Use "
Labs a�Matenals Onn ,
I Bwldmg S — 1 Building Pennn Fee S Induata,how fees Jiterrnined:
x :- O Smndud C:ry/Town Applieatirm Fea
3.Electrical`= S'� i
OTomlPro)ectCast,-(Item6).s mulupher x
J. Plumbing S S 2 Otha Fen S "
J:.Mechanic3l (NVAC) ` fy ., ."
Ust
SuMronal (F�rc . S ;y Total AllFea 5
Check No: Chick Amount; Cash Amount
6.Tots)Project Cost:" Paed m'full " ; ❑Outstanding 8,alance Dur:-
�m(lti�� 6�Z'S
a .
SECTION!: -CONSTRUCTION SERVICES
15. kensedCon froctler5opervisor(CS6) cs—U0 -I-��
L mme Number F.sp1irIaiun I)aw
N,une of 1L I hd �� U%WSL type We below) LL
Ixreri ion
Address U I Ilmestrictd to)S.COD Cu..Ft.
R:.. >Restrieted Id2=Farm "-Dwellin
sin M - ";011
RC, ' Residential Itoofirst Covering
felcphoor - ,WS '> Raiiiiid l WiklowaedSi ' . ..
- SF` '; .Iteshkrmial:Solid Fuel"Bumf A Iiaruro instollatiun ,
yj�Reglste►e Honelmpny�twentCtiatnetar�HlC)
42rr;t.� o�n► o \ ( RegismianNumM .... '
III Cu Name at)IIC R ntram Name
Expiration Dow
Sid we ewe>t� Telephwe, J
SECTION 6:WORKERS'COMPBNSATION7NSURANCE A MbA' IT(M G L a:IS7 j.23C(6))
Workere Compensation Ins mnec affidavit muss ba.eorrtpkred athd`submiued with this application. Failure ro provide
this affidavit will result in the denial of the"Isaume of the building pettnfl
Signed Affidavit,Atuchea Ya .... O No .......O
SECfiO1V I'm OWNBR AUTHORIZATION TO BB,COMPL6TED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIIBS ROR BUILDING PERMIT
1. p t wskl1 as Owner of do subject property hereby
audwrize to ad on my behalf,in all matters
relative to workowner
r ,by'thia building pemhil epplieahon /
SECTION 7bs OWNERS OR'AUTHORIZED--AGENT DECLARA770N
Owner cr Authorized Agent hereby declam
that the statements and information on the foregomg-appiceatton are robe and accurate:ro the best of my.knowledge and
behalf. � -
P �
siamat artTvtter or mharized Agem pax
Si utmler thepoinsaiia.Dim ticior ,
NOTES:
1. An Owner who:abtatns a building permit to d0 hnown work or an owner who hire a6'unregistrndxnntractor
(not registered in the Norm°ImprovetnenCConOxtor IHIC)Program) wall AM
(no to the arbitration
program or gwrarity fund tutdv fN.G.L c`1 42A Othc►tmportoanfomwion:on the HiC Program and
Comtruction Supervnso Ltcensittg(CSL)can bx`famd.tn 7g®CMIt Regulations 110 R6 and 110:R3.respectively,
±. When substantial work is planned.provide`thefo inmiatron below ;
Total floors aren(Sq:FL) tiucludhng'gar age,finished basemem/aaies decks or porch)
Gross living arcs(4 FL) HakitaMe room coven
Number of ftreplam Numbs of bedrooms
Number of bathrooms Nomber of kal0batks
Type of heating"system Number ofdc"pucka
Type ofcooling'systera Enclosed' Open
). "Total ProjM Square Foa tl e'may be sabsuroted lot"Total Pr w Cost"
wn39 I � w�s9
I
— 1i95/S DI�iWlSn6Y<I SOZ7 IDeLDI'n'tAsil 36 L$
' - ctnssr I W92�
Lail" —�_ 1 -
-
SD
31R"T
C. eWzt.,n aID W213y
I L`� SNEE
3M
REF
— W3L21
Tp'L-3393 -�
1
ALL DIMENSIONS AND ® DESIGN PLANS ARE PROVIDED FOR THE FAIq DESIGNED FOH _ 0 DATE BY SCALE DWG
DWN NO.
SIZE, DESIGNATIONS USE BY THE CLIENT OR HIS AGENT IN
GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED WITH IN 7.0T11J �_SI D'=f(=�VERIFICATION ON JOB THIS CONTRACT DESIGN PLANS REMAIN THE �{\�/'
SI E AND ADJUSTMENT TO -'-PROPERTY OF THIS FIRM AND CAN NOT BE / d-I J '
FIT JOB CONDITIONS. National KI[chen&Bath Assodatlon USED OR REUSED WITHOUT PERMISSION.
N 16116yWa1
I
CITY OF SM.EX4 NANSSACHUSETI'S
]LIMING DEP.MMIEti7
120 W.MEMGMN STMT,Yo FLOOR
TM(978)745-959S
FAX(978)740-9846
KI5t8ERLEY DRISCOLL THOMM ST.PMRRE
MAYOR
DiRECiOR OF P(:tiLIC PROPERTY/B[:II.DING CO\LUISSIO;•iER
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 ofhauler)
The debris will be disposed
/o\\f in
(name of facility
(address of facility) I
s' a of permit applicant
date
•hbns�trJ.k
r � ]he Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Sovet
Boston,MA 02111
Ulf www massg'ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElecWcians/Plulnbers
Applicant Information Please Print Ee 'bi
Name (Business orpnizationandividua►):
Address: UV\&Lk\ i✓
City/State/Zip: \SJ-U�"Ps\ lJ A1b Pho6e#:
Are you an employer?Cheek thcappropriate boa: Type of project(required):
1.❑ I am a player with 4. ❑I am a-general wmraeanr and I
6. QNewooashncl�n
canpbryces(tun and/orpart time).s lmvehaed do sub-oouuaetors .
2.0 I am a rolminapriewr or parr listed on the,attached sbeet.1 ?- Remudelig
sbip andhave no employees These sub oemhactms have 8. Demolition-
workmg for me in any capacity. workers'comp.msmanm y- Buildiagailditian
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] offices have exercised dick 10.11 BlechicalrePurs or ad itions
3.❑ I am a homeowner doing an work rigbtofexemption per MGL 11.[Q Plumbing repairs or additions
myself[No works; comp. c.15Z§1(4),and we have no 12-0 Roofrepans
insurance required.]t e,ulployee&[NO warms' 13.[� O&a
COW in�mce regoIIed-) .
•tnyappl-ammtamtder�boaSrmudahoffimaateseefimbelow&mi g�irva 'aompm P r>o
t liomeovmae adm sobmd Gs affi&vd and ceft 9yme ddag ea wmteud Pon b&e COW&mabatmsultsbuifta aewarank m&eating such
iCmhncto[s�atcbedcndsbmt mu�eamblM®addgiond abatsbo�voiggflsnma MBe wb-ooehaetusmd were map-poliwinoosnafiay.lam an employer that lspmvk%w wwkers'eonWmmBon kmrayweformy employees. Belowis thepoltcy andjob&e
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address:
City/SfatdZip:
Attach a copy ofthe workers'compensation policy declaration page(showing thepolicy number and expiration date).
Failure to same coverage as minfred under Section 25A ofMGL e. 152 can lead to Ge iWosition Ofcriminal penalties of a
fine up to$1,500.00 and/or one-year as wen as civil penalties in the fflrmofa STOP WORK ORDER and a fine
ofsp to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations of the DIA fbr insurance coven a vtxifieatmn.
l do hereby fy u er pains and penattles of perJury that the Infarmatlon provided above is true and correct
'
Phone M -SS W
OJJiehrl use only. Do not write in this area,to be completed by city or town offish t
City or Town: PermillUcense p
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Ibwn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: --