137 MARLBOROUGH RD - BUILDING INSPECTION .. �� ,:T.� �
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JNS,PECTA�,PR1DR Tp A PERMIT B,�WG GRANTED
� CITY OF SALEM
N�\ "� � ,•`�. `�```�\ Date `/a/Oy
��. s�.ii.., J�. —�/��
a,'`.'�i ,��7 WeR1
�.� 2oning District�_
Is Property Loeated in �r Looation of
the Historic Distdct? Yes No�\ Building /37 �'J13�R��OROUG'//Rp
Is PropeAy Located In
. the Conservatlon Area9 . . Yes,�No_ .
, BUILDING PERMIT APPLICATION FOR:
Permit to: i
(Circle whichever apply) Roof, Reroof, install Siding, Construct Deck, Shed Pool, I
RepaiNReplace, Other:
PLEASE FlLL OUT LEGIBLY& COMPLEfELY TO AVOID DELAYS IN PROCESSING
TO T TOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the fotlowing
spec'rfications: _
Owner's Name Joh/V %-o/� R /S T/�.C,[, I�
Address & Phone %�� /�j/�R.L B�R r� U G'H hD (9�b�1 7�'o a"�y/ �
ArchRect's Name I�aQ�=RT 11 U/y/�/-/
Address & Phone /cs ) ' - �s �S �,F" (p�81 �y6- G�'9G I
Mechanics Name �� ,.. _ ''�V�'�Fa �%� ,
Address 8 Phone 3UU SU/'PGL` /a✓k R,�v,�R� c �rrr� �-a�� yy,7
Whet Is the purpose of building9 /NG�RvaN�J �5 w��i�rii✓G�' ��o o� .
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Matei181 Of b�dlding? Cob[RF�TE ti.C?F'FL If e dwelling,for hoW many iamilies? I
WIII building coMortn to law9 Y�S Asbestos7 iYp
Estlmated wst o U "= Ciry licenae x U(,� � � GS O O �3�
fla�e Improve�ene �
\` Lic. 1 l/�'79,5�'
� \��,v� Si ature o Appli t
S NED UNDER THE PENALTY
OF PERJURY ,
DESCRIP'TiON OF WORK TO BE DONE
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MAIL PERMIT TO: nn L s Rf�' M c� �r- /-' �n.^c_
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No. \,_v�
APPUCATION FOR
PERMIT TO
LOCATION
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PERMIT GRANTED
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APP��D
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INSPECTOR F BUILDINGS
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- ` PLOT PLAN OF LAND IN SALEM, MA.
: - DATE:9-9-03 I � . i ,
SCALE: 1"=40' � �
OFFSETS SHOWN ARE APPROXIMATE BY TAPE SURVEY
BAY STATE SURVEYINGASSOC. INCI., I
100 CUMMINGS CENTER, SUITE 316J, �
BEVERLY, MA., 01915 ' ' �;y,
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Massachusetts Department of Environmental Protection �T'��' "'
Bureau of Resource Protection - Wetlands
DEP File Number:
' WPA Form 5 - Order of Conditions 64-0369
Massachusetts Wetiands Protection Act M.G.L. c. 131, §40
� i
� A. General Information
lmportant: SALEM
When filling F�Om: 1.Conservation Commission
out forms on
the computer, 2. This issuance is for (check one): � Order of Conditions ❑ Amended Order of Conditions
use only the
tab key to 3. To: Applicant: IIIIIIIIIIIIIIIII'IIIIIIIIIIIIIIIIIIIIIIIIIIII
move your
cursor-donot John Forristall 200406Z190775 Bk;23019 Pg;99
use the return a. first Name b.Last Name c.Company
key. 137 Marlborough Road 06�z��2006 is:a�:mm OTMER Pg 7/��
� d.Mailing Address
�6 Salem Ma 01970
� e.City/Town E State g.Zip Code
�^ a. Property Owner (if different from applicant):
Same
a. First Name � b. Last Name a Company -
d. Mailing Address . _. _______ ___
e.Cityffown � f.State g.Zip Code �'��
s. Project Location:
137 Marlborough Road Salem
a.Street Address b.City/Town
9 0276
c.Assessors Map/Plat Number d. Parcel/Lot Number
Latitude and Longitude, if known (note:
electronic filers will click for GIS locator): e.�atitude f. Longitude
s. Property recorded at the Registry of Deeds for (attach additional information if more than one parcel):
Essex � �
a. County �b.Certificate(if registered land)
17193 455
�c. Book d. Page
�. Dates: May 12,2004 June 11,2004 June 11, 2004
a. Date Notice of Intent Filed b.Date Public Heanng Closed c. Date of Issuance .
a. Final Approved Plans and Other pocuments (attach additional plan or document references as
needed):
Plot Pian of Land
a.Plan Title -- --- � -
Bay State Surveying Assoc. Inc. Robert Jarries Sotiros
b. Prepared By c.Signed and Stamped by
1" = 40'
d. Final Revi;ion Date e.Scale
. f.Additional Plan or pocument TiUe , � g. Date
s. Total WPA Fee Paid: $55 $15 $40
I a.Total Fee Paid � b.State Fee Paid a Citylfovm Fee Paid
r
�f �
' Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands DEP File rvumber.
� ' WPA. Form 5 — Order of Conditions s4-osss
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
, G. Recording Information
� This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in
which the land is located,within the chain of title of the affected property. In the case of recorded land, the
Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land
subject to the Order. In the case of registered land, this Order shali also be noted on the Land Court
Certificate of Title of the owner of the land subject to the Order of Conditions. The recording information
on Page 7 of this form shall be submitted to the Conservation Commission listed below.
SALEM
Conservation Commission
Detach on dotted line, have stamped by the Registry of Deeds and submit to the Conservation Commission.
-------------------------------------------------------------------------------------------------------------
To:
SALEM �
Conservation Commission
Please be advised that the Order of Conditions for the Project at:
137 Marlborough Road 64-0369
Project Loration DEP File Number
Has been recorded at the Registry of Deeds of:
County Book Page
for:
Property Owner
and has been noted in the chain of title of the affected property in:
a3o�G q�j
Book Page
In accordance with the Order of Conditjons issued on:
co l a � I�;
Date
If recorded land, the instrument number identifying this transaction is:
� ��
InsWment Number
If registered land, the document number identifying this transaction is:
Document Number
Signature of Applipnt
wpa(ormS.Eoc• rev.fiH0/04 Page B o(B
�
i PUBLIC PROPERIY DEPARTMENT
, •�• 120 WASMIN6TON STpEkT, 8RD FLAOR ' .
SALEM,MA O i�70
', ' TEL (978)743-93➢5 EXT.S80
� FAx (�78) 740-9646
STANLEY J. USOVKZ, JR.
� Mwrae -
DISPOSAL OF DEBRLS AFFIDAVTf
In accordance with the provisions of MGL c 40,S34,I aclmowledge that as a conditioa
of Bnilding Peimit#_ .all debris resulting&om ttie construcdon acOivity �
G ml
Sovemod by this Building Peimit shsli be disposed of m a pmperly licensed aolW-weabe
�P°��tY.as de�aed by M(�,c III,S150A.
�a���a��aof� woov TRUCK/NG" i�;��aor
Location of Fac�ry �
r r�y —`-�s /0 O � ��I
Si aWre of e�mit App D ,
' FULLY complete the follbwing info:mation:
(PLEASE PRINP CLEARLI�
Nsme of Peimit Applicaot
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Fum Namq�f atry
�300 sUF F o�/� /�v,[-� !� fR� /'�N � ai3� I
Ad�re�s>Ciry&State �' '
i 1'he above statute requires that debris from the demolition, re�ovation,reheb or oWa
1 alteration of b�rild'mg or s�ucnue be disposed in a properly-liceased solid-waste disposal
faciliry as de5ned by MGL cIIi, S 150A, and the buildiag permits or lioenses sn to
indicate the locaaon of the fsciliry.
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Workers' Campensation Insurance Affidayit
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. . witha prinupal pUu of businrss at:
36� S�F F'��.k AV,E= i?kv��'� /�A o 2-%s�
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do hereby'ccrtify under sht pains �nd penaltits of pvjmy, thas: . I
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O I am an employer providiag workcn' comyensacion coven�e tor my cmployces workint on
chis job.
� C /Vl� � U✓C ��.?o7 ��� 9� --a � . .
Iruurance Compa�ry Poliq Numbcr
1 am a sole propriecor nnd have no one workit►= for me inptry capadtY•
O I am a sole propriesor, gcnml con:nccor or homeownet (cirde or�e) and hsve hired the
consnaors listed bdow who have she iollcwin� workvs' compensation yolicies:
Consncsar Insuran�e Company/Poliq Number
Convaccor Insurance Comparry/Po1iq Numbet
Contractor Insurance Company/Poliq tJumber
O 1 am � homeowner perfcrming �H tht work myself. • ,
I vnoen:anc wi�coo7 of�he w�Knmi.�D� iorwarae w dx ORc<el Imuiq�w+n ot [ht DIA lor coxrate�e*+�c�oo^an0 Wt�/�b�e
co.xrai� v rec.+no uno�r Seccon 25A of MGL 1 S 2 c�n kaa w V�r:nvos�uon of cr'r�nai o�naiKs corsuuni oi � fnr e(oo�mi I.SOOAO ab/x one
r<�n' :caruom„mc v �cr0 v ci.i o��viva v+ ine Iorm of� STOP W ORK ORDf R ano� f+u el S f 00.00 a oay ni+ut^'a.
Sign d this , /� � _day of '
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Li nseei F ,iices Guilding Gcp:rcn+enc
LiccrLing Ecare
Sekecmms Office
�,�1th Gec:r.mcnc
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I . POOLS BY McDUFF, INC.
300 Suffolk Avenue �0/�7/O�j
REVERE, MASSACHUSETTS 02151
Phone (781) 289�4917
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SECTION �5W"P �' `o GR6TE'�`�'M�,c�� NOTES ''
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