OSBORNE HILL DR - BPA B-2007-837 RETAINING WALL JOB 05 Bat.,.rF t4 k., SU R PI v! a a.N
ROOME & GUARRACINO, LLC
Structural Engineers SHEET NO. S/9L �M . { �T OF
48 Grove Street CALCULATED BY ti DATE 3 Ti Q
So:.ierville, MA 02144
Tel 617.628.1700 Fax 617.628.1711 CHECKED BY DATE
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JOB �/SBOYLNE • 'I L�'✓ �yBOlyls lON
ROOME & GUARRACUNO, LLC
S4cFM , M�? Z o�Z
Structural Engineers SHEETNO. /� of
48 Grove Street CALCULATED BY 5Z DATE 3 0
Somerville, MA 02144
Tel 617.628.1700 Fax 617.628.1711 CHECKED BY DATE
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ST NE.. WALL .sMAGG .BE if r2t/cT�;O of ROUGHG y SNAPE�:
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OFFN ASf0162 710 Bg VF1ZiiF1fP AT I-nmE aF coNSTRUCTIoN•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,;,Wi Ml:, `R (I)LA.
12C WA5711-N(;i ONSi'RELT 4 SAITM.A\Si\u!
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
Z skl,we 4015- jle-A 1/1 o 9 WA fl-1,;9'
fil 2CC0fdanCC With the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of NIGL e 40, S 54;
BUilding 11crant # . -- is iSSLICd with the condition that the debris resulting from
this work, shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
l name of itautzr) --
&Y'X-fll CWr 7
Hie debris will be disposed of in
A-4el
lnnme of facility)
of
penm applicant
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
auaaF,rrx,ttmtruAu
MAYM
120 VA4o"O. Satan?•SALDs,MASM:FR �01"a
TEL Workers' Cotmpeasadon Insurance Affidavit» Bnt!(`s9s9s •FAx 97p7109
A derslContractor%WacWd&nypbmbera
Name i - l:
Address:_, AIX Z d
City/StaWZip.
Phone# -7fl- 33 qt� fpP ;
Are_yyi as employer?Cbeek-*a SWO"is box:
1. I am a employee With 4. ❑ I am a generalcontreansand IType ,� laireo
employees(fill and/or Pftl-ume�• have Diced the 6• ,�/Ne�w�
2. subconttactpe ( �edaa
❑ I am a sods peoprieter or partner- hued on the anacbed shear,J 7. Q Remodeling
ship and have no employees These
workingfor me isWorkers,
have 11.
any capacity' workers ��ia�soce. ❑Demolition
[NO workers comp, inavance 5. Q We are a corporation amd its 9. Q Budding addition
or a
o$icen have exercised their 10.Q Electrkd repairs d ftoy 3.❑ I am a homeowner doing all work right of
myself.(No workers,co �OPd00 Per MGL l l.Q Plumbing mpaits a addidoma
insurance required]I mP a 152,¢1(4J,and we have no 12.Q Roof employees.[No workers-
*Any*Any
+ppttaan ma docks ban et aagm slap ax as m•reeetea tNlow conqL mots required.] 13.❑Otbar
Homeowan who a0eu atla S"co rk 'bowies srir e c im.aampaopyae
sksgotiocs
'coamKtm 69 clock alb beg mime a ,� wawa?mace bin ses�+Ance bsek
!am an em 'b0"ms m,oams sudeoeaaatpe wortnms' atl6rmeDo�ploys tJYar b provldlnl workers coteperaradow Ins
Injonmallota uronee jw"q'employees. Below is the pollgy and/ob alas
Insurance Company Name:
Polity#or Self-ins.Lic.Av Gf/G`c 3DDo 7a/01LDo6
6 9xPhdonDate: IP115 -17
Job Site Address:_ /l� �! �`wgtelji.Ls'
Attaci a copy of the workers'compessattos
Failure to Polk?decdsrsdos page(stowing the Polley number and er
secure coverage as requited under Section 25A of MGL c. 152 car lad to the P�dos ef.
fine up to S 1,500,00 an&or one-year imprisonment,as wcll err civil mP tion°f° penalties of a
of up to$250.00 a day against the violator. Be adv' peneities in the form of a STOP WORK ORDER sad a line
Investigatioru of the DIA for' teed that a COPY of this statement may be forwarded to the O�of
uuarnaee coverage verifuation.
!do ksrebp eerri/yPafoe and e
Pe ojprr/ary thatotilt iejorsetdom govlded above lr nsm"d rorrees
Phone /- del/ si "
OfJkid use only Do nol writs Ls deL alto,lo be completed by c4 w town o,Qieki
City or Town:
Permialceass 0
Issuing Authority(circle ono).
1. Board of Health I.Building*Department 3.C1ty/fowa Clerk 6.Other ;, Electrical Inspector S.plumbing Inspector
Contact Person:
-------------
Phone t
- - EI`IrOF SALE)it - - - -
"' / PUBLIC PROPERTY
DEPAR'L'i'VIENT
I:I�Mcn cY D�151'ULL
MAYOS I WASHINGWM ST IM•aALLx XtiSAdrl:5t11S 01970
TEL 978-74S.9S9S•FAX 97sJ40.9s"
APPLICATION FOR THE REPAIR RENOVATION% CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY VaSTLNG
STRUCTURE OR BUILDING
F1*0ORMATIONme: �S or/le—dress:
�D�-ham 1h11 OX s® ��
Properly is located in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: i Dr�/t. rS e5 J
Address: SDX 7ft)
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per Floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
40
6,19Zl)
s�
Mail Permit to:
What is the current use of the Building?
Material of Building?_ If dwelling, how many units?
Will the Building Con to Law? Asbestos? s_
Architect's Name
Address and Phone
Mechanic's Name '
Address and Phon4-30dZ5-4` 7d� dLf2 .�� %
Construction Supervisors,License# HIC Registration#
Estimated Cost of Project$ U Ad Permit Fee Calculation
Permit Fee S 5!�- Estimated Cost X$741000 Residential
Estimated Cost X$1 Ui1000 Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields,are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
of
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