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42 MASON - BUILDING INSPECTIONI � } R � I � s- G k -#� �35/3 .. .. G y �, : ; �BiNIiS��f ffL Y� �1PPROVE{) $Y N+IED tX .11�P,�TL?A .PF�R Tp A .PERMIT B,�1NG GRA � �CITY OF SALEM J :,,�;, � = 0 �(�}/-� �;;� •,� '�.,�� Date No. '�� " � � 'h� i �lii S�.7(l' `�S � .�\i .�'?� \'��'�G� .. 8 I �\, ,m�nsc�" Is Property Located In � Location of ya ��sow -�� the Historic Oistrict7 Yes_No Building Is Property Located in �„ the Conservatlon Area? Yes_No� BUILDING PERMIT APPLICATION FOR: Permit ta (Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool, epair eplace. Other: PLEASE FlLL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specffications: - � Owners Name S TFV�" ��' L & Address & Phone �{� �}�'S UW � �{ I��61 ) Z S�� Z�q� ArchitecYs Name CI � M���W� S L' �'R �°R� ' Address & Phone w�SH���� 7�� ��{� �3`3� I Mechanics Name 4 I Address & Phone ( � I Whet is the purpose of building? ��f/,G�" �-- Mffiedel ol bullding7 It a dwelling, for how many families? WIII building confortn to law9 X L S Asbestos? U I N ' Estlmated cost �`� , �' o � Gty license r P' State ucense n C s� 2 So3(, � 3smE .T,^^„rrovement V I Lic. 1 /1 � � Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE �'��i�,6 a/'/'/��.� J'�✓« Tc a ,�' , `�Jl�j'P�✓ �60 ���.-/h��' l MAIL PERMIT T0: M 1 K� ��0 R (Er1l � � C i DER W(JLL ►Q D � �a� R��v � P��Ba�y � �.� ��v���J W l4�-g � d I q� o � �w vE� � 1►��- o�9a3 � � — � , '� �� No.f� APPLICATtON FOR PERMIT TO / /�/� y -- . �"7�/'�`oi / I.?n��% . �� �Q� LOCATION � a- hw3�n �7�ei J ' (��tii� rc� . w. � PERMIT,GRANTED . ��`J�li� O�o Ll�'j . AP OV�D . ��lw-z;•„� � � � � � � � . ` _ ���.--,/ _ INSPECTOR OF BUILDINGS � � ♦_ �4 p� 1! ��. LL f rlj '� T. � !'r. . � - „ �. :,- , � � . . , . . .. _ .. � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ——-� ; � ' ___=i , ,� , � I I ' � " „ �� , _ I „ , ;� � , , � , � � „ ' , , � I ; ;; � �i �\ � � . ; ;; i �� �\ � ,� � � , � , � � � .. � . . � . . � . . . . . � � � � � . : . . , . . . . . . � . � . � � � �� � . . � . � . .. . . . � , . . . . . . . L�--- ---- �\y . 1 ;, H.H. Morant & Co., Inc. , ., Architects ; �, ;, r.o. eox aass ,. 69 Lafeyette Sheet I ; ,� Salem, Maesachueette 01970 , , �, , i. � . . . � � � . . . . . . . � . � . . . � �� . �. . . � ..� � . . . �. . � . . .. _ . �. . .. - . . . � . . � � . .. � rr� . � .. . � � � �� . . . 1 New 8'-f�" Baae a uJall Cainets ;; �sas) 7aa-s3sa ; w/ Kitchen 5tyle Smk „ (508) 740-9161 Fax . . . . . , . ; . � . . . . . � . . . . . . . . . . . . � � . I .. .. . . . �. . . . � . . � . � �I .. � . . � �. � .:. � � . . � .� . ' � . Coeiulbetc .. . ... . � . . � . . . .. ., � .� . . : ., . . � . . / � . . . ./ \ . . � . .. .. � � �..�.. �,. � .. . �. . . . �4. � . . . � : . � .. � . , � Job Number. � � . . . . � O . . . .- - ------.— � � . .�-----� � IL----.-y _ �� .. � . . / :.. \ . . . . . . . .. � ` NNM ��-�2� , I �--- —y , ;' �wsting — ; 1 �ICP ; '�; o.ta: ; lavatory , Exis ing Mop 5ink UJork Station U1ork Station . , ��brUary 23, 2���0 to emam C9'-�"xlm'-(l�") f9'-(D"xl(I�'-m") Office ' No. D�b Revidon B}^. , � C9'-6'x14'-m") ,, � � _ _I 3/6/(d6 pmv ; _ ; Added Kitchenette , _ � I , „ , ; : , ; : � — � , Low Partitons „ w/� Wovd Ga� ,:�., :. : �'� - , Office ., ; .. ; , . > lim'-m"x14'-m") �� . . ; � I ; Project: , ; ; :. :.. : ... , Ma St , ; ; _... So , ---------- ; 41 n r��t �---- � ; R�novation , � : , , i i ; � nit #� , � � - > Lavatory " � � � - � ; C6'-m"x�'-5") ,, ; � Conference I � Office ; Office `' I , � Cl2'-m"xl5'-6") � C9'-m'xl2'-m") C9'-m"xl2'-fI�") O ;; , � � > ' ' , „ . � � .::: , � ` I ', ; ,: � � > Shower .? '� 5alem, MA (I�19�� � , � ' � ; ' ,; C4'-3"x�'-9") < ,; ; I I I I , , ----- ------ , _ , :...... .. ... .. _. :: � °. � ': _ � ; � i ti � ;; „ i _ � �xistin Overhead I I , Door �o Remam , ; , Partial First ; _ : �loor Plan i " Proposed , � sa.��: ; � 1/4�� _ �� ��� . „ . . . . �.. . . .� � . . . . .. . .. . . . . . . . . � � . . � _ . .. . . . . . . . . . . . . .. � . . . � . � . . . .- . � Dr�winQ Nom6er, . � � � . . . ; - - ; k1 � _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 fi ��rti�l �irst �Ioor �l�n «ro�os�ol�, 1/�" -=- 1'_�" - � +�,�,� m�-mz�. �2�m�� , I. ____ ___ -- _ -,-- _ --- -�----_- � - - _ _ __J �--�,- . � . . . � � � � � � � . . .._ . . ... ... "`_y.'_'. .._.._._, _. . _ - __..., . . . . •J_ . � . � . . � . � � . �. . . . . � � � . � . � . . � . ._......... _"__._ . . � � �. . �'_ " " ' . .��' ' ' " " ' _ " _ _ ' _ _ _. _ " �" " ' " ." ' " ' _ " " " _ ' _ _ _ " _ _ " _ _ _ ' '. _ _ " _ _ _ _ ' _ _ . . .� . .. � . � . . � � . . � � . � � � . I . ' � ... . � . �. . . .� ' _ ' " " ' " ' _ ._ . . . . _ _. _.' . ' ' ' _ " " " '.' ' '. ". " ' " " " " ' ' ' ' "�" ' ' _._ _ _ _ _ ' _ _ _ _ " ' ' ' ' " ' ".' ' ' " ' " ' ' ' " ' ' " " " " ' " _ ' ' _ _ _ _ ' ".' � ___ . . , " ' " ' ' " ' ' ' ' " " . . . . � . . . . . . . . . , . . , . � ��----� � —--� � , �� I , � � ;:. ,...: . � , :: .:::< �o ��p ,.:.:..: ':',..; . � ' � I . . � 110 � 11�Y � . � . . .. . . �. - . � . � � � � - � . . . . � . , � . �, � .. � I � .. � � � . � . . .. i . . . � . . . .. . � . . � � � . � . � . .. � .. . . . . .. . � . . . : � . . �� . . . � . . - � � . : - . .. . �. . ��. .. .I . .. // . \\ .. . � . � .�. .. . � . . . . . . .. �. � � . .. . � : . . . � .. . . . � . � . . . . .. . � � . �. � .. .� . �:� � . i �. // ��\ . . �. . . � � � � . � � . . � dV . . .. . . � . . .. . . � . . � � � � . . . . . . . . . .. . � . . . . . . . . . . .. . . .. .. . � � . . � . � . � :. � �� . � � . I � : . � , : �---------\�y , '' H.H. Morant & Co., Ina ; Architects , ; P.O. Hox 4485 ; 69 Lefeyette Street � � Selem, Maaeachaeetta 01970 New 8'-m" Base s UJall Ca�nets , , (sss� 7aa-s3sa . w/ Kitchen Style 5ink , (508) 740-9161 Fax , .. . . � �. �... .. � � . ... .. . .. � I . � � .. . .. . .. �.. . ��..I . . . .. . .� . � �� . . � �. � Coeiultmlc . , . . � � � . . .� . � . . � � . � . . . . . . . . . . .. . . . .. . .. � . . . . . . . . . . . . . . . . . . . . . . . . . . ' . .. I . . . . . . . . . � . � . � . . . � . � . , � . .. . . � �.� . . . . . . . . � � .. � . . . . . . . .. . . . . . . . � . . . . _ . . .. . .. . . , . . . . . . . . . .. .. �.. � � � . � . . � . � � . . . ' � . .. . � � . � . . . � .. . . � . . . . . . . . . . . �� . I . . . . . � . . . . . . . . .. . � . � ./ � � , �:..,, /.. � � . : � . . � � . . . ' � . . . . . .� ; . . . . . � . . . . . � � � � lob Nnmber. � O ------- �---- -y IG_----y : : i �-----y NNM ��-�24 ' �xisting ; NGP ? ' � Lavatory , �ePbrudl" 23 � 2��6 ; � Exis ing Mop Sink UJork Station UJork Staticn ;` y � , � to emam C9'-m"xlm"-m") (9'-m"xlrD'-m") Office , 1 . 3i6im6ao�.�on amv , I I (9'-(o"x14' (I�") I', , p � , ; Added Kitchenette I� , i , _ � - , � . , � � � ,--� ', Low F'eartitons ; ; w/ Ulocad Cap _ ; _ Office , , . , ' ' > Cl�'-m'xl4'-�°� , , I � � ; Project: , ; ....:.... , ---------- ` ; ;: � �41 Mason Street �---- � ; Renovation � � � � � Lavatory ', ��llt #� � � C6'-!a"x�'-5"J , ; J Gonference � J Offic� Office � ; , , : ' � (12'-m"x15'-C") � C9'-m'xl2"-m") (9'-m"xl2'-fI�") > O , , , , , ; � � _ � � , � � ` ` ::. :. ::.: , , I I ; ; � � ? Shower �, Salem, MA m197m , I I C4'-3"x"1'-9") ` I I I ; ? I ;: , , , , , ,, � ----- ` ------� ; , , .... _ � � � � � � � ; - T - , Existin Overhead � I ' Door �o Remain � , � Partial First ` . ; Floor Plan � , , l , ;' Propos�d ', sa.ia 'I , ' l/4° 1' f�° . . . . .. , . . � . . .� . . , . . . � . . . . . ; . . .. . � � � . �. � Drawing Nvm6er � � . . � � � � � . � �. � . . � . . . ..� .� � � . . . . . . . . � . . � � .. � .. . �.. .� � . � � . � . � . . � . � . . � � . . � � .. � � . . . � . .. . � � . . � . . . � i . . . .� . . .. � . � . . . � .. . . . . . .. .. � . . . . � � . . � � � � � � .. . . - - - - - - - - - - ' - - - " - ' - - - - - - - - -` - - " - - - - - - - - - - - - - ` - ' - " ' - - - ' - - - " -- - - - - - ` - ' - - - - �- - - - " ` - - - - - - -�- - - - - - ' . . . . . . . . . . . . � . . . - - - - - - - - ' - - " ' - - - " - - - - - - - . . " - - - - - - - - - - ' - - ' - - - - " - - - - - - - ' - ' ' - " - ' ' . � ��rti�l �irs�, �loor �I�n C�ro�os�ol�, 1/�" = 1'-�" 1 I HHM m6-fa24 C2/fd6) � _ —_ . _ _ ._ —_._. __ __ ____ �_: _ �T � Tl+e Commomvealtb ojMqssochr�sett� � Department ojlndusfrid Accidents O,atct oflm�tst�'gotlons � 600 Was6ington Sded Boston,MA 02111 www�n�as.cgou./�Eii Workers'Compensadon Insurana A@4davit: Bu7derslContractors/Eled�idans/Ph�mbers Aa�licant Information • Please Print LeQiblv Name �tion/t�diviaua�: F.SS 6-K Crn:,✓TI/�.o�a,c,_ �,�r-��'1 Address: s' ! � .r� �i rL«C ' City/StateJZip: �6 ��u�/V'. . �vy��'. �'�6° Phone#: 9 �r� s.�/ — -1 F:l,� Are you a�employer?Cheet t!t a�►PruP�irte boz. •� � .,.. rte Type d projat(rcqdred): 1.0 I am a etr�bya with � .` ¢. �I am a gencal cantrar�r and I 6: ❑New constraetion emRbYoa�&D anNor pazt-time).' Lave L'ned�e aoD-ecetraclDn 2.�I am a sole proprieror or parmu listod oa tha attached ahat t 7. [�Remodeling sLip and Lave m employea These sub-contracw�a have 8. ❑ Demolition worltin�fqr me in�qr,capacity. p'0��� �mP•.�� y Q �8 addidon ' [No workae'com�,insurwce 5. � We an a wtpoiatan atid it�' • 1Q r«loaed.l_� �. ,. ; ofAeasbave .exei�uodthea � Electricatnpaus or additiand 3.0 I am a 1�omeowmt.domg all worlc right ofeac�py�per MGL' t l.ej P�bIDB re�yiro ar additiom mysel£[No woikeis'.comp:. _ a 152,41(4X and we have no . �T��ad�3 t .. .. . . �D1oY� IA[Q woiketi` ��'0 Roof repam .. comp.i�ix rajuiied:]' 13.❑ Other '�Y sPPlicmt th�t chrets box Nl�i eLo 8U�t�e seqion bebw�6owin`meq..p�'�py Dob�S m�y�. t Homeowmas alq atmit mii a�vil mdie�maY�e do�i dl wart md�ee hJis q�de ooqpi�tasmuitaLmt�neM e�hvit mdicetinQ eueh � �Cono'acpn�at cbeek misba�t`m�rt etteched�o edditiOnJ�eLeat ehow�io�the mm bfibe�ab�n md fie6 wodcen'cmp,PuTeY�('ommtioo. :p: . . ...__. .,,, � I anr a{►en�ployerr�Lt provldl�;workers'ewnpcnaatloa/h.iyrwiesja nryenfployeds Bdow b dFspo!!iy rndJob sl�e lnjonxsrlos. Ins�aance ComparyName: Policy#or Self-ine.Lic.It: Expintion Date: Job Site Addre�: Lyh,����. Auach a copp ott6e worken' eompeas�lon polley decluatlon page(gpaw�ng the pollcy namber and aptration date} Fa�7ure to scwre coverage as req�¢ed u�ec Scetion 25A of MGL a 152 can 1pd�o the auposi�on of cri�al penalnp of a fine up to S1,SOO.00�d/or ono-Y��+�ea;a�weD as civi7 peaalup m�e focm of a STOP WORIC ORDER and a Hne of up oo 5250.00 a day agamst the'viola0or. He advised tbat a oopy of tLie statement msy be foivvatdad Ao the OtHce of Imestigations of the DlA far msutance covetage veri5cadoa !Oo IYarby���nde►" Peeabla olpt7iury that du Jnjormaffon provlded obope b trw an!con+ect D �`� . �6 n �1: 1 � ,�31 c���(/.f O,�'leld wr onl,p. Do iwf w�ele rlrl�arry m be eonipls�d by e!ry alowA o,�'ld�L Clty or Tow�n: Pa�mWi.lanae N I�suing Authorily(eircle one): 1.Board ot Hatth 2.BuUd(ng Departmeut 3.Ckp/Powu Clert 4.Elatr(eal Impator S.Plumblag Inspector 6.Other Coetact Penao: Phone M• Information and Instructi�ns ,` ` ` , n ror iteir ea+�loY� 1y(assachusctts Gene�al Laws c,�apar 152 rcqu'ves aII omploYta0;6D Pmvx�.wo*kP� ��ti0 �tract of hire, p�t m this stad►te. an iu�P�Yoe is defiacd�"...evuY.De�in the saviu Qf,another u�det anY exprese or imPlicd.°�or writtea." , � . An employe'�4 de5ned as"an iadividual,Pazmas�P.���0°�b0n or other legal entitY.o*�Y two or mora � � aod mc�din8 the 1e�1��ee of a daceasad emPloYa.or 1Le of tLe fore�oinB aBs6�1°a�° c6��' or other leppl eotitY,cmPbYm6 emp�°Y°� Howevq tha rcceivc or austa of an ifldivfdoal,P���P.�0n of thd'` not mon than thca�and wbo nsides theiein,or the o�� oamcr of a dwcllioB lmuse bavinB ns�o do mamtenana,oonsauction or repair wor�on snch dwelliaB Loage ' �,�g house of anoffier wLo emPbys P� be damod�o be an empbya. or�the�ounds or bu�dioB aPP�tLereb sball not because of sach emploYmwt also smtes that"evtry state or toal lieensing�Benc9���0�d the laeaanee or MGL ehaPter 152,$25CL� ���e a bodnm or to con�traet botldtng�la the eommonweaML fos mY rmewal ot a lieenee or pa'mit ������eompliana wNi the Irsarua cov�ra�e n9�-» aPPtleant w6o ha sot p staui"Neither the commo�ucahh mr anX of ib poHtic�l�mne ahaII ABditionanY.MGL chaPt�152:4�a� ofpubtie wod�nnUl accePtable evidena af comPtisnu with the iasurance enta into anY conuact E��e P�� �p the co�ractinB���� - raquiremean of thie chaPw Lave baa presa� APPHea�s , . siWation wd,if Please fiA,ont the wockers' cou�asen°n affidavit comPleWY,bY checki°S�boxea that apptY tu Ya� necessary.snPP1Y�-CO�act��(s)namc(s�address(es)and P�ne numbe[(s)a1on8 with thea catCficatds)°f myurance. L'mrited 1.iab�'��P���or L�Liab7itY Fazmecshipa(LL�)with no emP1oYae other tLan the �or partnas, an,not rcqaira►�o cartY workas' campeusation insurana. If an LLC or ld.P doe�have Be advised lhat this atHdavit maY be submiaod to the Departmmt of Induatrial �1oy�'a���r�of'msuiance covaage. Alw bq`,sure to sig�and date the a8ldavM. 'Ihe affidavit shoald �ed�m ihe�ihat tLe appfication fa ffie p�mit or lianse is 1xin8 ralnested,not the DeP�°t of to obtain a workers' SLou1a You Lsve aaX 4nwCona�B iLe lavr or if yon an ra�ed . �shonld enter theu Industrial'Accideme. ��e D�at thS nnmber psted bebw. Self-�.cow� compcnsation Pc1ie7+R� sel4=msurance tianse mom�be�on the � a� Ctty or Tow�s Oi�elal� , Pleave be sun tbat ffie af�davit is wmplete a�printcd lepblY. The Deparm►ent Las prwided a space at the bot0om of the af5davit ta�Yon ro ffi out iu ihe eveut the Offiu of Imestigations Las oo contact you regard'a�8 tLe aFPlicant. Please be sure to fill'm the pecmit/bcense numba which will be used as a refuace�mber. In addition,an aPPlicant 1Lat must snbmit amltiPle Per�����PPlications in any�'ea Yea*��0Dh'submit one af6davit mdicating current policy mformation(if necessary).?�,�"Job Site Addrese"the apPlicant shonid write"all bcatione in (�5'°r ^p of the a�avrt�t ha�ban o�ci�llY sta�od ac markcd bY du city or town msy be Pmvid°d t°du° mwn} �' f�t s vatid af8davit�on 51e 6or tb0ue pemtita or liceasa. A new affidavit nmetbe Sllod out pcL I applic�nt at pme s lianse oc pamit not telated:to auy busineee or ooa�ercial ventare year.Where s bome owna ot citiza i�obtaioin6 �NOT n4n�d m�Rleu this affidavit (ia a dog liccnsc or pemrit�barn lavea ete.)said pason� would l�e to thaolc Yrn►in advana for your coopaadon and sl�ould yon bave anY 4a�� The Offioe of ImesoBan°ns ua a caLL plcase do�t hesitate�u Sn' The DeparUmenYs address,�i�PLone aed f�[namber: The Commonwealth of Massachnsetts Depaztment of Indusaial Accidents OtBct of Investlgadona 600 WashinBton Street BosWn,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7�49 Revised 5-2�ros www.mass.gov/dia � • V CITY OiP 3ALEM� MASSACHUSgTTS • � PUBLIC PROPERTY DHpARTM6NT 120 WASMINGTON $TRE[T, 311D FLO01� SALFM, MASSACNUSETTt 01970 STANL[Y J. UfOVIC� JR. TRLHPMONt: 978-7qy_g39� EXT. 380 MAYOII FAX: 97S-76O-g944 - S812n1 BII��II�DCD�ttmant D�brfa Dlsoos Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Pern�it is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposai facility ay defined by MGL Chapter III, S 150 A. The debris will be disposed of in; (Location of Facility) _��'�/� Sign�i're of Applicant ���� o� Date