NURSE WAY - BUILDING INSPECTION � � ► 4po Gtc. ! l3
The Commonwealth of Massachusetts OF
Board of Building Regulations and Standards CITY ITYSAL
co 4(
Massachusetts State Building Code,780 CIVIR RevireJ:Nur 20/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
U) One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date pplied:
Building Otlicial(Print Name). Signature - '. �!Date
SECTION 1:SITE INFORMATION'
i.l Property Ad ress: 1.2 Assessors Alap'3r Parcel Numbers
i _'P AA 1 ) s'.
[.to Is this an accepted street?yeses no Map Number Parcel Number
1.3 'Zoning Information: 1 1.4 Pr� tyODlmens(ons:
Q.1
Zoning District Pr"poll Use Lot Area(sq tl) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
15 t ' to l� 30 3c�
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? . municipal On site disposal system ❑ -
Public
Private❑ Check If e p F y
SECTION2: PROPERTYOIVNERSHIV 1j
p 2.1 OwnertofRecord: KA Q�
�1me(Print) City,State,ZIP �l
��i « �� (�b)3')-��8ti iz�li adG(J
Nu.andSucet Telephone Email ddrcs;
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Constructiong Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: r.a,1 Sin L -c" {r_n%Att. c.,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S O 0d 1. Building Permit Fee:S Indicate how fee is determined:
U0 O ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 1,4000 2. Other Fees: S
1.Mechanical (FIVAC) S Oav List:
5. Mechanical (Fire i Total All Fees:3
Su ressiun) •.
Check No._Check Amount: - 'Cash Amount:_
6.'Tutal Project Cost: S abb 0Jb ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.I Construction Supervisor License(CSL) W lolgD3 5 as un
5l 1> I)tM 0.iv-60 _ License Number Expiration Date
Name of CSL[folder List CSL Type(see below)
Cc J c-f y t-,J at: u-t O Description
No.avid Street
T
M� U Unrestricted(Buildingsa to 35,000 cu. It.)
�l ( ,-, y(�1� R Restricted I&2 Fantily Dwelling
city/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
rt SF Solid Fuel Burning Appliances
�1g ba�'ci� RpSS•'IXMs�$RA tl/`I��•e•(t1•rS 1 Insulation
Tele hone Email address I I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP TA hone
SECTION 6:WORKER$'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢25C(6)).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uance of the building permit.
Signed Affidavit Attached? Yes.......... No........... O
SECTION 72:OWNER AUTHORIZATION,TO BE COMPLETED WHEN,'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I h e attest under the pains and penalties of perjury that all of the information
contained in this applicatio i and accurate to the best of my knowledge and understanding.
_la, )� 1�
Print Owner's or A 'or' d r • rut
Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Liar have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www mass eov!oca Information on the Construction Supervisor License can be found at tvwtv.naass.�xn:!dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) y330 (including garage,finished basementlattics,decks or porch)
Gross living area(sq. R.) d 3 Habitable room count
Number of fireplaces_ I Number of bedrooms +I
Number of bathrooms — Number of half/baths I
Type of heating system b• s Number of decks/porches 1
rypeof cool ingsystem tC �— Enclosed Open pC
1. `Total Project Square Footage"may be substituted I'or"rot l Project Cost"
\ The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: O'nA LL.0
Address: �n► ��yv
City/State/Zip: j #, �* y[118 Phone#: 3 all -714j
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
}►�y� or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.Ip1 I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate, auto,etc.)
/t employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers, � �
with no employees. [No workers' comp. insurance req.] 1 JE Other
"Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I our an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lie.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the viol r. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insur c overage verification.
I do hereby certify, under a' n enalties of perjury that the information provided above is true and correct.
Si nature: / Date:
Phone#: 1 J
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that."every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
Kok �
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION k, DATE
ASSESSORS DATE l� G
93 Washington St.
CITY CLERK
93 Washington St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
Jefferson Ave nI ;
PLANNING �l��l%` DATE O/LBI LOI(F
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRIC?NTION
DATE
48 Lafayette
FIRE PREV DATE
29 Fort Avenue
HEALTH DATE f� f
120 WashingtcWSt.
BUILDING INSPECTOR DATE
120 Washington St.
I
I I
MAP 14 LOT 33 't
= N/F
Itl BARTLETT & STEADMAN y /
I DEVELOPMENT CORP. \
(LOT 226 ON REF. )OPEN SPACE
r �
I �
I
BRASS
DISK _ 525_52_30'E
80.09' t
-- — \� MAP 14 LOT 33
3 I / LOT AREA \•�I BARTLETT STEADMAN
s 1 �15:03 `y 7,200L S.F. 30.4' \ I DEVELOPMENT CORP.
',I [•y:, W 3Z9•�ti 1 (LOT 226 ON REF. /1)
OPEN SPACE
w 15.8' t
1 I DECK a 116x ' DECK 116 0414
PROP. ylt IITS't .`?.
GARAGE PROP 1'i-00170
P ] W (24•xP4•) SINGL lb
0 0
SLAB=115.5' RESIDENCE ; m PROP. GAS BY
x3(28' 2') SERVICE PROVIDER /
I p im,r� FF=121.6t r_y /
D(�IR9f!'- SLAB=113.0
f Imo • 1 PROP. tYs 0
{ • "5,'e .% SCH40 PVC
Yea
EXIST.tt-'are: 111-@:5 /
IRON I 10.5, ` 12" DRAIN /
ROD t INV-109.8t .
-N2S$2 lLJI! - 113xO
Y s,,c:.AtK I 77.24' f, • _ -. I(.,_ �~
15.0+'L2,PROP. i"0 TYPE K "_2 n739 R=145110'1 7.3_.�A \
WATER SERVICE
NU R5E WAY EXISTNG PROP
t. I L I WATER, SEWER RET1 WALL \
& GAS STUBS 4't,TALL (MAX.)
(PRIVATE RAY - 40' WIDE)
+ ..� "._ice ••�- �.a � — . ,_ .. _ t12:6O .
MAP 14 LOT 33
BARTLETT STEADMAN
µ'OS i DEVELOPMENT CORP. /
(LOT 226 ON REF, ip1)
- I OPEN SPACE
o �
PLOT PLAN
FOR BUILDING PERMIT
ASSESSORS MAP 9 LOT 259
NOTES: 11 NURSE WAY
1) BOUNDARY SURVEY BY LE13LANC SURVEY SALEM, MASSACHUSETTS
ASSOCIATES, DANVERS. MA. -
2) PROPERTY IS SHOWN AS LOT 227 ON - RECORD OIINER:
LAND COURT PLAN 856-13. BARRECO & WMM.-IAN
3) FOUNDATION DRAINS TO DAYLIGHT • y�
RECOMMENDED. DEVELOPMENT CORPORTATION
� pp�
REFERENCES, .3"
A N c PREPARED FOR:
mm
1) L.C. PLAN 856-13 �" CMl +� ;DOMINIC PEZZULO
2) LC. PLAN 856-J y 4`' PREPARED BY:
�•^ �' GROM ENGINEEIIING GROUP, LLC -
0a!t;�'� 495 CABOT STEW, ZRD FLOOR
BEVERLY, MA 01915
ZONING OISIRICT - R1 '(078) 927-5111 _
MINIMUM LOT AREA - 15,000 S.F. DECIMER 19. 2016 -
MINIMUM FRONTAGE - 100' ]._�. -
SETBACKS
FRONT - 15' - HOR. SCALE IN FEET
SIDE - 10' O 20 50 100
REAR -;30• .- ry .
1
I I
I
1 MAP 14 LOT 33 4
N/F
1 B T & STEADMAN
DEVELOPMENT
y
DEVELOPMENT CORP. (\
(LOT 226 ON REF. #I)
OPEN SPACE } \
P
• BRASS
' /DISK { .. 11I< 1 80.09' T - T
MAP 14 LOT 33
1
, N/F
i.01 I
F 200t S 7, . . `30:4' .. BARTLE77 & STEADMAN
1., T
i
. f15.03 r ` I DEVELOPMENT CORP.
37.9' i �" (LOT 226 ON REF. #1)
c ' .1., . . . . . . _....tLL... ivI OPEN SPACE
a 15.8' j - 3 7.5'x12 I` .1'4,I4
116x0 1 DECK �118x
E'•, q ys
PROP.
GARAGE PROP. 1'(24'x24') SINGLE-FAMILY 18 O
o S.AB=115.5' RESIDENCE PROP. GAS BY
FF--81216t p SERVICE PROVIDER
SLAB=113.0 /
z1' DRIVEWAY /1'
` I PROP. 1Y4"0 9' DEEP PORCW' I�`ly7
r_S
EXIST. !
L ii .
IRON V I 105 ((''12" DRAIN
ROD 7 _ 3�y 13x0 1 1 FINV=109.aL !
1
wMLK P I 77.2,V
J
rz,. ,�• { 150' l L-Z.85 0:
^,a.?PR WATER SERTY0EVICE ' -.28 I[1,39 =145TN' r1 '� \
I
NURSE WAY �EXIs1 NG PROP.
r + ( WrAIER, SEWER RET! WALL
112.1,rz (PRTVATE WAY - 40' 11IDE) & GAS STUBS 4'± TALL (MAX.) v
_ 1,IZ.so.,..
R'M- '.72.1'3 t
MAP 14 LOT 33 `` \
I I I BARTLETT & STEADMAN
�4 W^S DEVELOPMENT CORP"
(LOT 226 ON'REF. #1)
I OPEN SPACE
0
i
PLOT PLAN
FOR BUILDING PERMIT
ASSESSORS MAP 9 LOT 259
NOTES:. 11 NURSE WAY
1) BOUNDARY SURVEY BY LEBLANC SURVEY SALEM, MASSACHUSETTS
ASSOCIATES, DANVERS, MA.
2) PROPERTY IS SHOWN AS LOT 227 ON
LAND COURT PLAN 856-13. n RECORD OTFNRR:
3) FOUNDATION DRAINS TO DAYLIGHT BARTLET & STEADMAN
RECOMMENDED. xoeEar DEVELOPMENT CORPORTA170M
R FF-F E a�, h
) L.C. PLAN 856-13 :(I AMR • PREPARED FOR:
p• h
2) L.C. PLAN 856-J \�� x � DOMINTC PEZ2TTL0
PREPARED BY:
GRIFFIN ENGINEERING GROUP, LLC
(2.(9'j6 495 CABOT STREET END FLOOR
BEVERLY, MA 01915
7ONMG DISTRICT - R1 (978) 927-5111 '
= MINIMUM LOT AREA - 15.000 S.F. bECEMBER 19, Z018
MINIMUM FRONTAGE - 100'
SETBACKS SCALE: 1'=2O'
FRONT - 15' HOR. SCALE IN FEET
SIDE - 10'
REAR - 30' 0 20 50 100
d
a
I
I I
MAP 14 LOT 33
7
I BARTLETT & STEADMAN h
DEVELOPMENMEN
T CORP.
(LOT 226 OPEN N REF. N1)
P
I
BRASS
DISK _ - S25'S2730"E
—�
' MAP 14 LOT 33
LOT AREA \I N/F
I q 'I ��,...,•S 7,200t S.F. 30.4' BARTLETT & STEADMAN
DEVELOPMENT CORP.
II �• 37.9'v f (LOT 226 ON REF. g1)
W l l OPEN SPACE
15.8' 7.5'x12' I •a.la
II`I 1 118x0 ffFnTM DECK 1 116x F
Ir; E_ cW I
PROP. #11
GARAGE PROP. olio
y a w (24'x24•) SINGLE-FAMILY Io q
0'FI,`o SLAB=115.5' RESIDENCE e m PROP. GAS BY /
ay olo (2 ) n SERVICE PROVIDER
I;n o FF=121 1211 63. /
PROP. SLAB=113.0 /
DRIVEWAY I
PROP.
I } '-_ IA C DEEP PORC
SCH40 PV /
- t
EXIST.
i �. 11 L9) /
IRON H I 10.E 1 72" DRAIN /
ROD '1® ..N25�''2'3Ryl 113z0 ! 1 INV=1`098+
—
` ,eATn P- _I 77.24' I \� � 0
� •-a_ - 1PROP. 10 TYPE K 145700'
WATER SERVICE
NURSE WAY IS NG PROP.
I I WATER, SEWER RET. WALL
(PRIVATE RAY - 40' HIDE) AS STUBS 4't, TALL (MAX.)
. — . t'2.6_ . 6 v
0 "
� I
.ha r
MAP 14 LOT 33
BARTLETT STEADMAN
�WOS &I DEVELOPMENT CORP. /
I I (LOT 226 ON REF. #1)
OPEN SPACE
o �
PLOT PLAN
FOR BUILDING PERMIT
ASSESSORS MAP 9 LOT 259
NOTES 11 NURSE WAY
1) BOUNDARY SURVEY BY LEBLANC SURVEY SALEM, MASSACHUSETTS
ASSOCIATES, DANVERS, MA.
2) PROPERTY IS SHOWN AS LOT 227 ON RECORD OWNER.
LAND COURT PLAN 856-13. ^ BARTLETT & STEADMAN
3) FOUNDATION DRAINS TO DAYLIGHT a sq.� DEVELOPMENT CORPORTA77ON
RECOMMENDED. �'o, RO6ERT "z
REFERENCES d/z cRIIx1R ,, PREPARED FOR:
1 L.C. PLAN 856-13 CIVIL y DOMINIC PEZZULO
2) L.C. PLAN 856-J ° '�
PREPARED BY:
GRIFFIN ENGINEERING GROUP, LLC
495 CABOT STREET, 2ND FLOOR
(z BEVERLY, MA 01915
ZONING DISTRICT - R1 (978) 927-6111
MINIMUM LOT AREA - 15,000 S.F. DECEMBER 19, 2016
MINIMUM FRONTAGE - 100' SCALE: 1"--20'
SETBACKS
FRONT - 15' HOR. SCALE IN FEET
SIDE - 10' 0 20 50 100
REAR - 30'
I
MAP 14 LOT 33
I BARTLETT & STEADMAN 3
DEVELOPMENT CORP.
(LOT 226 ON REF. #1)
I OPEN SPACE $
I �
I
BRASS
DISK _ _ S25_5
ED2'30'E
l 1
- IJ - -�_-
�-
\ MAP 14 LOT 33
i LOT AREA \ \I N/F
'• I qI �I,_ iq 7,200t S.F. 30.4 BARTLETT & STEADMAN
\ I DEVELOPMENT CORP.
'I 37.9'` (LOT 226 ON REF. #1)
W v 15.8' 17.5'x12' B
1T6x0 DECK I. . OPEN SPACE
0 1 I
1 I 116x F
N w I PROP. #11
I GARAGE PROP. I oohv
1" a w (24'z24') SINGLE-FAMILY Io 0
I o o SLAB=115.5' RESIDENCE 0 m PROP. GAS BY !
z o o (28'x32') n SERVICE PROVIDER
.� u I;n o FF= 1 I
Q z zl� \\ PROP. SLAB=113.13.0 I /
DRIVEWAY
PROP. IYi'0 5' DEEP PORCW' /I
_SCH40 PVC
v ����, 1119.5 EXIST.
IRON M I 10.5' ( 12• DRAIN !
ROD 7® _ 9a! 3D:W 113x0 ! I + wv-t09.ti1
1PROP. 1"0 TYPE K =145�0' , L'3.,0
WATER SERVICE 1 Z',\
I NURSE WAY EXISTING PROP. _
I `WATER, SEWER RET;. WALL
(PRIVATE WAY - 40' WIDE) & GAS STUBS 4't TALL (MAX.)
MAP 14 LOT 33
0 N/F
BARTLETT & STEADMAN
WOS i DEVELOPMENT CORP.
I I (LOT 226 ON REF. #1)
OPEN SPACE
o �
PLOT PLAN
FOR BUILDING PERMIT
ASSESSORS MAP 9 LOT 259
NOTES: 11 NURSE WAY
1) BOUNDARY SURVEY BY LEBLANC SURVEY SALEM, MASSACHUSETTS
ASSOCIATES, DANVERS, MA.
2) PROPERTY IS SHOWN AS LOT 227 ON RECORD OWNER:
LAND COURT PLAN 856-13. ^ BARTLETT & STEADMAN
3) FOUNDATION DRAINS TO DAYLIGHT a DEVELOPMENT CORPORTA770M
RECOMMENDED. RoeeR,• ziN�
REFERENCES: dIs GRIT y PREPARED FOR:
1) L.C. PLAN 856-13 �1" ovix DOMINIC PEZZULO
2) L.C. PLAN 856-J
e• PREPARED BY:
F?j. st GRIFFIN ENGINEERING GROUP, LLC
c,F
495 C STREET, FLOOR
BEVE 019
BEVERLY, MA 01975
ZONING DISTRICT - R1 (978) 927-5111
MINIMUM LOT AREA - 15.000 S.F. DECEMBER 19, 2016
MINIMUM FRONTAGE - 100' SCALE: 1"=20'
SETBACKS
FRONT - 15' HOR. SCALE IN FEET
SIDE - 10' 0 20 50 100 _
REAR - 30'