LOT 213 MARTIN LN - BUILDING INSPECTION City of Salem Ward
i
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT
IArPOIiTAW-AppBoant to conpwa a/Nwo /n soctJonc 4 4 A% 1V snd LIL
LOCATION
OF BETWEEN AW
aloe man .taro.
BULDWG LaF
&awtsoN o, t-c. t -. \\ LOT iiLL SLOCK
L TYPE AND COST OF BULDM -AN applAwts comply Parts A-D
A. TYM Oi11ovELENr D. PROPOs®UM-FOn-DEA+OUTIOW USE MOW RECEW USE
+ Lc�/�/1'+�rJ woo* MYdwoNd /1rr�YYn1Y
a ❑ AddOM(0 nadwd.I afar narrowafar 12 ffl�B+mW I Q Ar.MWMI.ttay.rbnd
hm,okv unit.daa4/wrr a pod A 131 tY Q Clnd�drr lWyaw
13 ❑
3 ❑ Af.robw(Sow,2 abo.y Of UrWA ana(Ir Ei1rr nrrrer 20 p rrsnrW
4 Q R.p.Y rtgYc.rrrwr ,. ❑ 11.Irrt ho11I.mad.w aomtllary- 21 Q P►"9MV
n 23 Q 9 w■1.
/ Q W�* w(In .Whw*n*dw,9Wrnarow ENW rw fjw a unr 23pN=wft OwNrkwad
of uru4 a WAOV In Pot 13) 1513 ar.1a 24 p 001M e.r14 WdwWWwd
B Q M.Mrw(nbcwlon► 1s O cwpwl 25 Q ^bft uMr
7 ❑ rmoo wewl arty 21 ❑ Sdlook Ift Ow O&Avdla r
t 7 Q onw-spoor 27 Q SbF8% WON
IL ow n3►+IP 21 ❑ Tarw4 as w.
/ p PrMr.(Ml.buok cwpwab r,nanplaB 2813 on.-spoor
inwa.lark 060
9 Q PUEOo(Fidw.4 SW.,w wad ap•.nn1w1+
C.COW kO
Nwr.ddrwld-DaovEa n dow propcaod tM a huk*v .s 1p d prac..Wq P+.na.
maahrahoR IwnbV w htaplok aawonry whout a.owtdwr oarooL caB.p�1GCoda�wlprd..nl.n — --_ pwecw.d" . - ad.pW = dowr.Wa1o.OW WMalp.bLokJ -
pint r ua.a a"Ouid'q r bWV a1v10ad.snow propo.sd u.d
fi 4`+.award ht aw ow od
In wa apo.�.c,oua(i Fkrr".._._.._.._d Odrr t.way.JE]
OST OF i1.1PROVEINENT -
TED CHARACTERISTICS OF BUILDING -for new buildings and additions, complete Parts E-L;demolition,,
is on Paris J S M. a#o&ws ski to IV
AL TYPE OF FRAME F. 1"5XVIAL TTPE Di NEAT94 FU6 (L TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL.
AYor"Iwap bowwv 33 �O= 40 �PttlC v prw.Y oonn.n► M Iron W unv.l Y
dod hanw J! Q Op 41 p PrMM.f"Pot to*MC)
buicNal per 77 ❑ EWMXAV M .s
.i,Iwcad rnnw+e+a 3813Cad L
PE WATER SUPPLY We/+we by an WrAdw, /
dr Spacb ]/ ❑ Odr-Sptrc/r Ptbfe a P"you eompwM ,W D Mr1 47 rLr-��6
_— Cl PrMaY(..K ciaewn)
I
i otlslaloes M. DEMOLITION OF STRUCTURES:
a mdre.dsaw= _
,e •ow,a,.,r nor d+low Has Approval from Histtxical Commission been received
A slows b.++a ••r1z fa arty structurs aver fifty(sD)Yam? Yea—_ No_
_. Dip Sob Number I
sO 'by and+ra so It !
tc ISAUM or OFF-aTrum PAarreea s..co Pad Control i
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?yes No
52
L wsaporrrss suaofeoe Ora W
E1eCUft~
F,A--- -- — Sewer.
of DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
bie'O"o F nrr.._..._...._....__ BEFORE A PERMIT CAN BE ISSUED.
N. COMPLEI E THE FOLLOWING.
Historic District? Yea_ No— (M Ye%plasae enclose doGurtentatoe from Hiss Corn.)
Conswayon Area? Yee—_ No_ (K yes pie enclose Order of Condltlone)
Has Fire Preventlbe approved and stamped Plans Or aPPikations? YeL_ No_
Is property located in the S.RA district? Yes— No_
Comply we ZankW Yee— No_ (H no,enclose Board of Appeal decision)
Is lot grandfathered9 Yee_ No— lH yea,submit documentationAl no,submit Board Of Appeal decision)
If new conetruc m has the proper Routing SI1P been enclosed? Yee— NIX—
Is Architectural Access Board approval required? Yes_ No_ (If yes,submit documentation)
Massachusetts State Contractor Licenses 7& 7 9 Salem License e
Home Improvement Contractor • Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(B)MONTHS OF ISSUANCE OF BUILDING PERMIT
If an extension is necessary,please submit
CONSTRUCTION 13 TO BE COMPLETED BY: in writing to the Inspector of Buddktge.
v. iDENT1mxnoN- To be completed by all applicants
Nyrp idwr Nm'bI.it/M(cfi.rtl YaY LP Code '4L rb
t
2
8 AOer�
:oMra[O LGenY nN
1
�titW z
E pr�
I hereby cw*that the proposed wont:s authorized by tM owrter at record and:hat I have been audwzed by the owner to-make this applicalm
a3 his authonzed 3gent and we agree to Conform to all 3pplicable laws of this;unsdicti0n
Sgr.ft, Karts Address Application date
DO NOT WRITE BELOW THIS LINE
n VALIDATION
FOR DEPARTMENT USE ONLY
Building
Penrd number um Gmo
Building t g Fn Cwadne
Permit issued
Jdrq lne IaCYV
Permit Fee s
Certilfat•of Occupancy s APOr
Drain Tile s -
Plan Review Fee s L nnE
NOTES AND Date (For depertmerK use)
s 0
4SV VI In 'r
c S
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by -
W ZONM PLAN EXAMWERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
WM OR PLOT PLAN•For Appffic"U"
O N
i
I
w
BeamChek v20051icensed to:DMS design, llc Reg#5234-65564
The Belmont Beam#1
Date:326/12
Selection (3)1 3/4x 9414 1.9E TJ Microllam LVL Lu=0.0 Ft
Conditions
Min Bearing Area R1=3.5 in' R2=3.5 in'
Data Beam Span 13.0 ft
Beam Wt per ft 12.48# Reaction 1 TL 2616# Reaction 2 TL 2616#
Bm Wt Included 162# Maximum V 2616#
Max Moment 8502 W Max V(Reduced) 2306#
TL Max Defl L/240 TL Actual DO L/397
Altributes Section(in Shear i TL DO m
Actual 74.87 48.56 0.39
Critical 37.88 12.14 0.65
Status OK OK. OK
Ratio 51% 25% 60%
Fb(psi) Fv(psi) E(psi x mil) Fc l (psi)
Values Base Values 2600 285 1.9 750
Base Adjusted 2694 285 1.9 750
Adiustments CF Size Factor 1.036
Cd Duration 1.00 1.00
Cr Repetitive 1.00
Ch Shear Stress N/A
Cm Wet Use 1.00 1.00 1.00 1.00
Cl Stability 1.0000 Rb=0.00 Le=0.00 Ft Kbe=0.0
Loads Uniform TL: 390 =A
Uniform Load A
0 0
Rt =2616 R2=2616
SPAN= 13 FT
Uniform and partial uniform loads are Ibs per lineal ft.
BeamChek v2005 licensed to:DMS design, llc Reg#5234-65564
The Belmont Beam#2
Date:3/26/12
Selection (3)1-314x 11-1/4 1.9E TJ Microllam LVL Lu=0.0 Ft
Conditions
Min Bearing Area R1=8.0 in' R2=8.0 in'
Data Beam Span 13.0 ft
Beam Wt per It 15.18# Reaction 1 TL 6014# Reaction 2 TL 6014#
Bm Wt Included 197# Maximum V 6014#
Max Moment 19544'# Max V(Reduced) 5146#
TL Max Defl L/240 TL Actual Defl L/311
Attributes Section ink Shear(in ) TL Defl(in)
Actual 110.74 59.06 0.50
Critical 89.42 27.09 0.65
Status OK OK OK
Ratio 81% 460/6 77%
Fb(psi) Fv(psi) E(psi x mil) Fc L (psi)
Values Base Values 2600 285 1.9 750
Base Ad'usted 2623 285 1.9 750
Adiustments CF Size Factor 1.009
Cd Duration 1.00 1.00
Cr Repetitive 1.00
Ch Shear Stress N/A
Cm Wet Use 1.00 1.00 1.00 1.00
CI Stability 1.0000 Rb=0.00 Le=0.00 Ft Kbe=0.0
Loads Uniform TL: 910 =A
Uniform Load A
0 0
R1 =6014 R2=6014
SPAN=13 FT
Uniform and partial uniform loads are Ibs per lineal ft.
BeamChek v2005 licensed to:DMS design, Ilc Reg#5234-65564
The Belmont Beam#2
Date:3/26/12
Selection W 8x 15 36 ksi Wide Flange Steel Lateral Support at: Lc=4.2 ft max.
Conditions Actual Size is 4 x B-1/8 in.,
Min Bearing Length R1=0.8 in. R2=0.8 in.
Data Beam Span 13.0 ft
Beam Wt per ft 15.0# Reaction 1 TL 6013# Reaction 2 TL 6013#
Bm Wt Included 195# Maximum V 6013#
Max Moment 19541 '# Max V(Reduced) N/A
TL Max Dell L/240 TL Actual Dell L 1366
Attributes Section ink Shear m TL Dell(in)
Actual 11.80 1.99 0.43
Critical 9.87 0.42 0.65
Status OK OK OK
Ratio 84% 21% 66%
Fb(psi) Fv(psi) E(psi x mil
Values Base Value Fy 36000 36000 29.0
BaseeAdausted 23760 14400 29.0
Adiustments YP Factor, Lc 0.66 0.40
Loads Uniform TL: 910 =A
Uniform Load A
Q 0
R1 =6013 R2=6013
SPAN=13 FT
Uniform and partial uniform loads are Ibs per lineal ft.
4
BeamChek v2005 licensed to:DMS design, Ilc Reg#5234-65564
The Belmont Beam#3
Date:3/26112
Selection (3)2x 10 SPF South#2 Lu=0.0 Ft
Conditions NDS 2001
Min Bearing Area R1=6.5 in' R2=6.5 in'
Data Beam Span 6.6 ft
Beam Wt per It 10.11 # Reaction 1 TL 2178# Reaction 2 TL 2178#
Bm Wt Included 67# Maximum V 2178#
Max Moment 3594'# Max V(Reduced) 1670#
TL Max Defl L/240 TL Actual Defl L/919
Attributes Section i Shear(in) TL Defl (in)
Actual 64.17 41.63 0.09
Critical 50.59 18.55 0.33
Status OK OK OK
Ratio 79% 45% 26%
Fb(psi) Fv(psi) E(psi x mil) Fc L (psi)
Values Base Values 775 135 1A 335
Base Ad'usted 853 135 1.1 335
Adiustments CF Size Factor 1.100
Cd Duration 1.00 1.00
Cr Repetitive 1.00
Ch Shear Stress N/A
Cm Wet Use 1.00 1.00 1.00 1.00
CI Stability 1.0000 Rb=0.00 Le=0.00 Ft Kbe=0.0
Loads Uniform TL: 650 =A
Uniform Load A
0 0
R1 =2178 R2=2178
SPAN=6.6 FT
Uniform and partial uniform loads are Ibs per lineal ft.
BeamChek v2005licensed to:DMS design, llc Reg#5234-65564
The Belmont Beam#4
Date: 3/26/12
Selection (2)13/4x 9-1/4 1.9E TJ Microllam LVL Lu=0.0 Ft
Conditions
Min Bearing Area R1=5.2 in' R2=5.2 in2
Data Beam Span 6.6 ft
Beam Wt per ft 8.32# Reaction 1 TL 3888# Reaction 2 TL 3888#
Bm Wt Included 55# Maximum V 3888#
Max Moment 6416'# Max V(Reduced) 2980#
TL Max Defl L/240 TL Actual Defl L/692
Attributes Section W) Shear in TL Defl in
Actual 49.91 32.38 0.11
Critical 28.58 15.69 0.33
Status OK OK OK
Ratio 57% 48% 35%
Fb(psi) Fv(psi) E(psi x mil) Fc L (psi)
Values Base Values 2600 285 1.9 750
Base Ad'usted 2694 285 1.9 750
Adiustments CF Size Factor 1.036
Cd Duration 1.00 1.00
Cr Repetitive . 1.00
Ch Shear Stress N/A
Cm Wet Use 1.00 1.00 1.00 1.00
Cl Stability 1.0000. Rb=0.00 Le=0.00 Ft Kbe=0.0
Loads UniformTL: 1170 =A
Uniform Load A
0
R1 =3888 R2=3888
SPAN=6.6 FT
Uniform and partial uniform loads are Ibs per lineal ft.
�a a
Generated by REScheck-Web Software
Compliance Certificate
ci
Project Title: Lot #214 Martin Lane
Energy Code: 2009 IECC
Location: Salem, Massachusetts
Construction Type: Single Family
Glazing Area Percentage: 16%
Heating Degree Days: 6268
Climate Zone: 5
Construction Site: Owner/Agent: Designer/Contractor:
Compliance:4.7%Better Than Code Maximum UA:299 Your UA:285
The%Better or Worse Than Code index reflects how dose to compliance the house is based on code trade-off rules.
It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home.
GlazingGross Cavity Cont. LIA
Assembly Area or R-Value R-Value or Door
Perimeter U-Factor -
Floor:All-Wood Joist/Truss Over Uncond.Space 1272 30.0 0.0 42
Ceiling:Flat or Scissor Truss 1272 38.0 0.0 38
Wall:Wood Frame, 16in.o.c. 2025 21.0 0.0 95
Door:Solid 21 0.200 4
Door:Glass 42 0.300 13
Window:Vinyl Frame,2 Pane w/Low-E 290 0.320 93
Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other
calculations submitted with the permit application.The proposed building has been designed to meet the 2009 IECC requirements in
REScheck-Web and to comply with the mandatory requirements listed in the REScheck Inspection Checklist.
Name-Title Signature Date
Project Title: Lot#214 Martin Lane Report date: 03/22/12
Data filename: Page 1 of 4
i4
Generated by REScheck-Web Software
f2f Inspection Checklist
Energy Code: 2009 IECC
Location: Salem, Massachusetts
Construction Type: Single Family
Glazing Area Percentage: 16%
Heating Degree Days: 6268
Climate Zone: 5
Ceilings:
❑ Ceiling:Flat or Scissor Truss,R-38.0 cavity insulation
Comments:
Above-Grade Walls:
❑ Wall:Wood Frame,16in.o.c.,R-21.0 cavity insulation
Comments:
Windows:
❑ Window:Vinyl Frame,2 Pane w/Low-E,U-factor:0.320
For windows without labeled U-factors,describe features:
#Panes Frame Type Thermal Break? Yes_No
Comments:
Doors:
❑ Door: Solid,U-factor:0.200
Comments:
❑ Door: Glass,U-factor.0.300 „
Comments:
Floors:
❑ Floor:All-Wood Joist/Truss Over Uncond.Space,R-30.0 cavity insulation
Comments:
Floor insulation is installed in permanent contact with the underside of the subfloor decking.
Air Leakage:
❑ Joints(including rim joist junctions),attic access openings,penetrations,and all other such openings in the building envelope that are
sources of air leakage are sealed with caulk,gasketed,weatherstripped or otherwise sealed with an air barrier material,suitable film or
solid material.
❑ Air barrier and sealing exists on common walls between dwelling units,on exterior walls behind tubs/showers,and in openings between
window/door jambs and framing.
❑ Recessed lights in the building thermal envelope are 1)type IC rated and ASTM E283 labeled and 2)sealed with a gasket or caulk
between the housing and the interior wall or ceiling covering.
❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated(without insulation compression or
damage)to at least the level of insulation on the surrounding surfaces.Where loose fill insulation exists,a baffle or retainer is installed
to maintain insulation application.
❑ Wood-burning fireplaces have gasketed doors and outdoor combustion air.
❑ Automatic or gravity dampers are installed on all outdoor air intakes and exhausts.
Air Sealing and Insulation:
❑ Building envelope air tightness and insulation installation complies by either 1)a post rough-in blower door test result of less than 7
ACH at 50 pascals OR 2)the following items have been satisfied:
(a)Air barriers and thermal barrier:Installed on outside of air-permeable insulation and breaks or joints in the air barrier are filled or
repaired.
Project Title: Lot#214 Martin Lane Report date: 03/22/12
Data filename: Page 2 of 4
(b)Ceiling/attic:Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any gaps are sealed.
(c)Above-grade walls: Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier.
(d)Floors:Air barrier is installed at any exposed edge of insulation.
(e)plumbing and wiring:Insulation is placed between outside and pipes.Batt insulation is cut to fit around wiring and plumbing,or
sprayed/blown insulation extends behind piping and wiring.
(f) Comers,headers,narrow framing cavities,and rim joists are insulated.
(g)Shower/tub on exterior wall:Insulation exists between showersttubs and exterior wall.
Sunrooms:
❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U-factor of 0.50 and the maximum
skylight U-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope
requirements.
Materials Identification and Installation:
Lj Materials and equipment are installed in accordance with the manufacturers installation instructions.
Materials and equipment are identified so that compliance can be determined.
Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided.
Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications.
Duct Insulation:
Supply ducts in attics are insulated to a minimum of R-8.All other ducts in unconditioned spaces or outside the building envelope are
insulated to at least R-6.
Duct Construction and Testing:
Lj Building framing cavities are not used as supply ducts.
Lj All joints and seams of air ducts,air handlers,filter boxes,and building cavities used as return duds are substantially airtight by means
of tapes,mastics, liquid sealants,gasketing or other approved closure systems.Tapes,mastics,and fasteners are rated UL 181A or ..
UL 181 B and are labeled according to the dud construction.Metal dud connections with equipment and/or fittings are mechanically ,
fastened.Crimp joints for round metal ducts have a contact lap of at least 1 112 inches and are fastened with a minimum of three
equally spaced sheet-metal screws.
Exceptions:
Joint and seams covered with spray polyurethane foam.
Where a partially inaccessible duct connection exists,mechanical fasteners can be equally spaced on the exposed portion of the
joint so as to prevent a hinge effect.
Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa).
Duct tightness test has been performed and meets one of the following test criteria:
(1)Postconstrudion leakage to outdoors test:Less than or equal to 101.8 cfm(8 dm per 100 ft2 of conditioned floor area).
(2)Postconstrudion total leakage test(including air handler enclosure):Less than or equal to 152.6 cfm(12 cfm per 100 ft2 of
conditioned floor area).
(3)Rough-in total leakage lest with air handler installed:Less than or equal to 76.3 cm(6 cfm per 100 11:2 of conditioned floor area).
(4)Rough-in total leakage test without air handler installed:Less than or equal to 50.9 cfm(4 cfm per 100 ft2 of conditioned floor area).
Temperature Controls:
❑ Where the primary heating system is a forced air-furnace,at least one programmable thermostat is installed to control the primary
heating system and has set-points initialized at 70 degree F for the heating cycle and 78 degree F for the cooling cycle.
Heat pumps having supplementary electric-resistance heat have controls that prevent supplemental heat operation when the
compressor can meet the heating load.
Heating and Cooling Equipment Sizing:
❑ Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code.
❑ For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial
Building Mechanical and/or Service Water Heating(Sections 503 and 504).
Circulating Service Hot Water Systems:
❑ Circulating service hot water pipes are insulated to R-2.
❑ Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the
system is not in use.
Heating and Cooling Piping Insulation:
Project Title: Lot#214 Martin Lane Report date: 03/22/12
Data filename: Page 3 of,4
❑ HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3.
Swimming Pools:
Ej Heated swimming pools have an on/off heater switch.
❑ Pool heaters operating on natural gas or LPG have an electronic pilot light.
Lj Timer switches on pool heaters and pumps are present.
Exceptions:
Where public health standards require continuous pump operation.
Where pumps operate within solar-and/or waste-heat-recovery systems.
❑ Heated swimming pools have a cover on or at the water surface.For pools heated over 90 degrees F(32 degrees C)the cover has a
minimum insulation value of R-12.
Exceptions:
Covers are not required when 60%of the heating energy is from site-recovered energy or solar energy source.
Lighting Requirements:
❑ A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following:
(a)Compact fluorescent
(b)T-8 or smaller diameter linear fluorescent
(c)40 lumens per watt for lamp wattage<=15
(d)50 lumens per watt for lamp wattage>15 and<=40
(a)60 lumens per watt for lamp wattage>40
Other Requirements:
Fi Snow-and ice-melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting
off the system when a)the pavement temperature is above 50 degrees F,b)no precipitation is falling,and c)the outdoor temperature is
above 40 degrees F(a manual shutoff control is also permitted to satisfy requirement'c').
Certificate:
A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window
U-factors;type and efficiency of space-conditioning and water heating equipment.The certificate does not cover or obstruct the visibility
of the circuit directory label,service disconnect label or other required labels.
NOTES TO FIELD: (Building Department Use Only)
Project Title: Lot#214 Martin Lane Report date: 03/22/12
Data filename: Page 4 of 4
® 2009 IECC Energy
Efficiency Certificate
Ceiling I Roof 38.00
Wall 21.00
Floor/Foundation 30.00
Ductwork(unconditioned spaces):
Window 0.32
Door 0.30 NA
Heating System:
Cooling System:
Water Heater:
Name: Date:
Comments:
- /'f a3zZ
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION
/")ar DATE
2/3 a✓'"�'"' D
ASSESSORS ATE
93 Washington St.
CITY CLERK DATE
93 Washington St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH DATE
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION Irlar f otne. DATE
ASSESSORS DATE
93 Washington St.
CITY CLERK ATE
93 Washington St. /�� ,1
PUBLIC SERVICES KtnLNd / DATEOLIIOq/7O�L tx� -T t#-u
120 Washington St. tv
WATER 4�t, DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING& o DL jjj�. J ATE �110 � h
120 Washington St.
CONSERVATION' ATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH DATE 3I2�1�'z
120 Washington St.
BUILDING INSPECTOR TE
120 Washington St.
f//gilZ " 26
Professional Land Surveyors & Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
S'4Z,Z-7i! MASS.
H7, 00
J
J L� Z/3
- v� ZOT z�z
�- Se7r
�`Sp 3G y:
11jlb /G �lJ.JG
I hereby certify to the
ZONE: ,-/ .; LOT AREA:/VOIUL_ LOT FRONTAGE: Building Inspector that the pro-
posed construction shown conforms
FRONT YARD: SIDE YARD: /6r-)- REAR YARD: to the dimensional zoning of
Mass.
SCALE: q<
DATE: /'<'�/2��f .7�1 ZU/Z ,�
REFERENCE: /BK PG Christopher R. Me�I:l P A R 3 A
No.31
104 LOWELL STREET ��
PEABODY, MASS.01960 ,N_
(508) 531-8121
FAX:(508)531-5920
Lfl� �.i3
` 1 C I"I-Y O F 5.1L& [, b L1SS.ICH l 5 ETTS
13LILDNG DEPAR MUNT
120 %V.iSHLNGTON STREET, lea FLOOR
TEL (978) 745-959S
FA.-c(978) 740.98.16
vj.%IBERLEY DRISCOLL
NLAYO.'t Tmonits ST.PtERn
DIRECTCROF PUBLIC PROPERTY/SUtiDiNG CONMISSIONER
Workers' Compensation Insurance AtTtdavit: Guilders/Contra(:torii/Electricians/Plumberf
Antllicant Inftrrmatinn Ptcaye Print Legibly
.N3111a S`t�L IM rtta �J r �,.�f5 ( �• .
Address:_. _log St.
City/State/Zip; �jC✓c ( ylIft 0191 PhoneH: 77d- ZS `l
Are you an employer?Check the appropriate byti Type u rnJect(required):
I.0 1 am a cmploycr with 4, I am a general contractor and 1 6, CTNOW construction
cmpleyeea(full and/or part-time).* have hirud the subcontractors
2.0 I am a sole proprietor or p;utnur• listed on the attached sheet: 7• ❑ Remodeling
,hip and have no amployeee These subcontractors have V. ❑Demolition
working for me in any capacity. workers'camp,insurance, 9. 0 Building addition
I No workers',camp. insurance 5. 0 We are a corporation and its
requlred,) offices have exercised their 10,0 Electrical repairs or additions
3.0 1 ain a homcowncr doing all work right of exemption per MOIL 11.0 Plumbing repairs or additions
myself. (No workers'sump, C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. (No workers' I j,0 Other
comp insurance roquirad.)
-,any arph'am our dncka box rl must alto 0a uuu the owliao below thawing their wakare'companssdun pulley innirmaQam
'I hvnvuwivne who,dmdt this amdevit indiering thy are doing all work and than hire oultide conassnom matt mhnit a now amdovil indicting.uch,
:0mmeloa that check this bull meet aoaehud an tddidunul had showing the none of the sult•cumnetate and their woeorm,comp,policy Intomta im,
f urn on employer that/r pravlding tvorken'cumprurarlun htsrarunee for my ernp/uyerss Below h the policy and Jub site
infurrnudnn
,
Insur;uice Company Name: ,J,j nt t7� �1 �y/t F 7 a,y ( �_.
Policy 4 or Salr•ins. Lio.d: V C A "1y O ,2 S7 2, Expiration Date:__
Job Site Address: Lod.- Z13 ra. +Gl, hAk S,(so{t ,s?., City/S1ute/2ip: (0l`{7J
Attach a Copy of the workers' compensation pulley declaration page(showing IM policy number and expiration data).
Kid=to wcuru coverage as required under Section ISA ot'MGL a. 152 can lead to the imposition of criminal penalties of a
tine tip to 51,500A0 undlur ane-year imprisonmen4 as well as civil penalties in the term of STOP WORK ORDER and a line
atop to S250.00 u Jay agoinst ilia violator. Ile advised that acopy of this,talement may W forwarded to ilia OI'lica of
Invrtlig�tiuns of the nIA for insunna unveragc vcritkaliun.
l du h.,prby ossify nuJer th u6ra and penullies✓f perjury that the ioformallarr pro viJaJ above iv irut at correct
fit
q7t .90?. z5-q
011hiul rue only. /lo aor Vritir in 1114 area, t✓ba completed by rrty ur bosun.rJJletuL
City or
I,tuiag Atdhurily (circla one):
I. Iluurd of Ilcullh 2. Ruildlm. Deparhnem 1. cityi ratan Clark J, F,leetrlc.11 Intpcctur 5, Plumbing inspector
0. Other
Cunl.tct l'ertnn:_ I'hnne.t: