32 PALMER ST - BUILDING INSPECTION No z City of Salem Ward
4cumn'�
i
APPLICATION -�
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete alp Rams in sections:1, lA 114 IV, and IX.
1. AT(LOCATION) i Cr I w r i t d rS`r- DIS RICT
LOCATION_ .
OF BETWEEN AND
BUILDING ceoss sr l _ MROsa LOOT
SUBDMSION LOT BLOCK SIZE
11. TYPE AND COST OF BUILDING -All applicants complete Parts A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE.FOR"DEMO_LITIO_W USE MOST RECENT USE - -
1 NOW building RaNdanthd NonreNdandd
2 ❑ Additlon(M residentlai,enter number of new 12 ❑ One hunty t8 ❑.Amusement,.recrestional
housing units added,if any,in pert D,13) 19 ❑ Chncil.other religious
13 �.Twoor more family-Enter number 20 ❑ Induetrlal
3 ❑ Alteration(Sea 2 above) ._ .. - -at units-.._. _ _:_:_.....__.................
�
4 ❑ Repak replacement '14 ❑-Tianalmt hotel motel or dormitory.'. 21 E] Perking 9ereas,
. Enter number of units- ..:... 22 ❑ ery.,Service station.repair garage
5 ❑ Wrecking IN mutCtemdy rwi*nW enter number 23 ❑ Hospital,i,n6Mionel
of units in Wilding in Part D.13) - - - 15 Gore ' - .
. _ _ � 9e_ _ 2C ❑.1JNice,benk,.prolessional-.
8 ❑ Moving(relocation) 18 ❑ carport, _ 25 ❑,Public utility
7 ❑ Foundation any. .. -- - - - 26 ❑ Schoot iftary.other educational
17 ❑ Omer-Specify . . 27 ❑ Stare%metientile
B.OWNERSHIP 28 ❑ Tams,towena
8 Private(indwidual,corporation,nonprofit 29 ❑:Other-Specify
insbkAk %etc.) .. ..
9 ❑ Public(Federal,State,or local government ..
C.COST (Omit cents) Nonresidential-Describe in deleil proposed use of buildings,aa,food processing plant.
` - machine shop.laundry building at hospital,elementary school,secondary school,college,
10. Cost of improvement ..__..__.___....m_...__..__.__... $ parochial school,parking garage for department store,rents]office bl ltift office building
at industrial plan.If use of existing Wtdtrg is beirg changed.enter proposed use.
To be installed but not included
in the above cost
aElectrical ...._..._..................._.__...............__.............
b. PtumbnV.._........_..........._._...._............_._......... "'-.:QIJ - 4/0
-a Heating,air conditioning.__..._..___„___,_._..__... ` /]P5� ✓t�'7 ''5 ! l�e/'_
d. Other(elevator,etc.)._.__ ✓ t
11. TOTAL COST OF IMPROVEMENT —__—_ '- - S V
III. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L;demolition,
complete only Parts J&M, all others skip to IV
E. PRINCIPAL TYPE OF FRAME F. PRNCPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL
30 ❑ Masonry(wag bearing) 35�S Gas 40)K Public or whistle company . �d� Central air
31�Wood Name 36009 41 ❑ Pdvale(septic tanK etc.) co ❑ Yes :.. 45 ❑ No
32 ❑ Stnctural steel 37 ❑ Electricity - - - 44
33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY win there by an can ator? .
p `
34 ❑ other-speciy 39 ❑ omen-sweaty 42'�vublio or p6aita comany ❑as vas 47 No
4:Y❑ Private(veil,cistern) .
fr
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
4S. Number of stories.............. ,.
49. of ..:it Has Approval from Historical Commission been received
di _.._..__......__...... .r. _.__. -for any stricture over fifty(50)years? Yes_ No_
nlensk
sa Tam land a eas0.n..___----....._.........__..._..._.. Dig SafeYNumber
K.NUMBER OF OFF-STREET PARKING SPACES ..
- Past Control:
Si. Enobsed......................................._......_._..........._._..
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
sx. outdaora...._._-------._..- ._._... .._. ._..._.. -: , Yes
No
L RESIDENTIAL BUILDINGS ONLY s ,.Water y _ • _
_ (X\
Full_ .._...____...__ _ . . Sewer:
54. alh 1 a.
b DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
bathrooms. BEFORE A PERMIT CAN BE ISSUED.
A
IV. COMPLETE THE FOLLOWING: ^sr : 4 =t
Historic District?'- Yes—. No__.(If yes,please enclose documentation,from Hist.Com.).__
Conservation Area? ,Yes_; No—„ (If Y?g:Please enclose Order of Conditions)
1.,4 ..s.. p
Has Fire Prevention approved,and stamped plans or applications? Yei�2 No—
Is property located in the S.RA district? Yes_ No
w
Comply with Zoning? Yes tr No_ (If no,enclose Board of.Appeal decision)
Is lot grandfatfiered? Yes-- No— (If yes,submit documentation/if no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yes `f No_
Is Architectural Access Board approval required? Yes_ No (If yes,submit documentation)
Massachusetts State Contractor,License # O Salem License#
Home Improvement Contractor# f t L Homeowners Exempt form (if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
i If an extension is necessary,please submit
CONSTRUCTION ISTO BE COMPLETED BY I in writing to the Inspector of Buildings
V. IDENTIFICATION - To be completed by all applicants
Name Mailing addmes-Number,street city,and state 23P Code TeL Nm
t.
Owner w
Lessee
2. r.1 r ;C w� I ISA 6e-'c c ji. 05Ts3 (.&-�yw6
Cmt2ctor _ . . - auddees.. -
License Na .
a
Archaed or .-
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his authorized agent and we agree to conform to all licaUe laws of this jurisdiction.
Signature applicant Address APP cation date
, o
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE
USE ON
Permit number
' I Use Group
Building 1 _ , `7 _ 19_ Fxe Grad n�
Permit issued r j
Building Live Loading-
Permit Fee $
A-
omvpancy Load
Certificate of Occupancy $ Approved by.
_Drain_Tile_._ $ Z;F
Plan Review Fee
TITLE
NOTES AND Data.(For department use)
r �
174 PP
A/��✓ �IvO n
t ,
S U
p/L AJ
CU S
a
PERMIT TO BE MAILED TO: 3
DATE MAILED:
Construction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN-For Applicant Use
O N
3Y - 0l �'9
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CERTIFICATE OF OCCUPANCY
LOCATION: EQ En I mx, r DATE AIM,,, 9_�,
APPLICANT: f '�
✓ ASSESSORS
FRANK KULI ---DATE: ��-
(93 Washington Street) Uc?�a ��`Cco� eD✓
CITY CLERK
CHERYL LAPOINTE % DATE: / /z 6
(93 Washington Street)
PUBLICE SERVICES
BRUCETHIBODEAU DATE:
(120 Washington Street)4 oo -
WATER
-DOTTIE THIBODEAU DATE:
(120 Washington Street)4i6 Floors
�SQ
CROSS CONNECT SjJSp�R'�- 52
BRIAN THIBODEA i� DATE:--
(5 Jefferson Avenue)
t
PLANNING DATE: it ?A06
(120 Washington Street) 3nd Floor
CONSERVATION COMMISSION r
rz# .¢¢14u,3/�_ DATE: It D(o
(120 Washington Street)3``Floor l
ELECTRICAL
JOHN GIARDI DATE:
1:48 Lafayette S t)
FIRE PREVE O
ERIN GRIFFINr• L- DATE: l d l
(29 Fort Avenue)
HEALTH
JOANNE SCOTT (_ DATE: >a 3-
(120 Washington Str 4ih Floor
BUILDING
THOMAS ST. PIERRE DATE: 3
(120 Washington Street) P Floor
R^
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xntat:ats:Y nRtrcotc
MAYOR 120 WA4•�Jti'[OTtSTnaar e
��.�01970
7U.97t1.745^9595 a FAX-9W40.9W
;.Workers' Compensation Insurance Affidavit: Builders/ContraetorsmeeMetans/plumbers,
Applicant Information Plea n
Legibly
Name(Busin"WO[pniauoortedividualy. O(Zeo x)
Andress:_ I 1./ i n n I Q/,t
City/Stateaip: ' (e r ors. QIV.41 Phone#
Are Yon an employer?Check the appropriate bon
1.b�am a employer with 4. 0 18111 a postal contractor and I TYPO Of Project(�ui�:
employees(ND and/or part-time).• have hired the subcontractors & ONew'conoucem
2. I am a soh proprietor or pArmeo- listed on the attached shear t 7. 7 Remodeling
ship and have no employees These VA-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp,insurance,
[No workers'comp.insurance 5. ❑ We Ara a corporation and its 9. ❑��a addition
required.] oRlcers have exercised their 10.0 Electrical repair or additions
3. 1 am a homeowner doing all work right of exemption per MOL 11.[]Phmtbing repairs or additions
myself.No workers'comp, c. 152,11(4),and we have no 12.0 Rooftepairs insurance required.]t employees(No works=, 13.0 Other comp.insurance requited.)
'Any wsHnt dal aski boa 01 ems am es oat M ncdm boon ataaA Wg m.tr.at..
Ftamaoa OMM rice shade NO aNldsva kM=dsa any an day a uad:and dm WN aoedda aieasa moHir awn at tCoenaebm daa cheek tlda box meat aaaehad asaddidanal scot ahoarEea tlu now b•em
t�ha anason and Qadr wtiataaa•oomR polky lalkamaQaa.
1400 an employer that fsproviding workers'compensation IasuranCOJof my eapployta Below 4 t
fnjorma lu policy andJob shY
tlon
Insurance Company Name:
Policy N or Self-ins.tic.M:__ dV(� 4 — 9 — 1 C/ Expiration Date: r� a
Job Site Address:Attach A Copy of The workers'compensation policy declaration page(showingthe
Failure to secure Covers es Pe�9 camber sad aspiration dab}
W required udder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fmc up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a if=
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of&@ of
Investigations of the DIA for insurance coverage verification.
1 do hereby ee Jj ender the pahar anti alder ofper/ary that the 1nJotmadon provided above is&w and cored
—2
` OJJkid use only. Do not write fn this area,to be coaep&ted by city o►taww 0Jj7c1
r
City or Town: Permlitucense M
�dssuing Authority(circle one):
- ft. Board of Health 2. Building Department 3.CltytTowo Clerk 4. Electrical Inspector S.Plumbing Inspector
6 Other
(contact Person
Phone p:
e iK.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
Pursuant to this stanaak an empfoyn is defined as"...every person in the service of another under any contract of hire,
oxpresa of implied,orsl or written."
assoeiatia4 corporation o r other legal entity.or any two at mom
An rsspfoyer is defined as an individual.pantaashlP. of a deceased employer.or the
of the foregoing engaged m alonnt enterprise,and including the legal representativesbye However the
of an individual.patmershq%ssaocmtlm or other legal ent[tY.employing thamilS.Or the occaPaH of w the
receiver or uthstee not mote than three apartments and who resides
owner of a dwelling house bxvin—house i sow �Ya Pia to do mainteneeca.coostrocants of mm work on rich dwelling haw
dwelling thereto shall not because of such employment be deemed to be an empbyer."
or on the gsonmde OF building appurtenant
152,12SC(6)ahto States that"every state or local datasing agency shag witbbeld the Issuance or
MGL chapter to operate a bedlam or te eoWrnet bnlldinge In the commanweakh for arty
r ppliez of•tleae$e or permit ameptabb evidence of eomptbaee wkb the bsswnnee coversga regnlrad
appneae!who has not produced s�25C(,n spa«New�commonwealth
nor anY of its political subdivisions shag
Additionally,MGL chapter of public work until acceptable evidence of compliance with the inauraoox
enter into any contract for the performance to the contracting amhoriry
requiremeau of this chapter have been presented
Appbcsnte
Please fill out the wodwe compensation affidavit completely.by checking the bones that apply dfic& situation and.if
aeceaeary,supply sub courractor(a)name($),addteas(es)and phone number($)along with their certificates �than the
instmanry. Limited Liability Compswies(LLB a Limited Liability Partnerahhps(LLP)with no
anaPloY
members or partners,are not requited to carry workers'co O°insurance. If an LLC or LLP does have
Be advised that this affidavit may be submitted to the Department of Industrial
employees.a Pow u of wrsrtce coverage AI'e be snn to sign[aria date the OWavif. The affidavit ahatld
nt Of
Accidents for
confirmation application for the permit er license is being requested,not doe a workers'
be returned to the city or town that the app the law or if you an required to obtain a workers'
ln&UuW Accidents, should you have any questions regarding
compenseten policy,please call the Depfrommt at d number listed below. salt-insured companies should enter their
self-insurance license number on the
City or Town Of dabs
Please be sum that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
egarding the app UCU&
of the affidavit for you to fill out e�the OffiG9°f InvcsdPdons nber which will be used as a r�efereoeeto number t your In addition,an applicant
Please be sure to fill in the paring applications in any given year.need only submit use affidavit indicating current
that must submit multiple Peron app applicant should write"all locations in_city or
Policy. (if necessary)and under"Jab site Address"the app the city a town maybe provided to the
of the affidavit has been ofHciaft stamped or marked by tY
Iowa). A copyfluvrepau or licenses. A new aradrvir must be filled nut each
applieser as proof that a valid affidavit is on file for
license a pit net related to any business err commercial venture
year.Where a bome owner at CWZGn is obtaining is NOT requiredto complete this affidaviR
mit
(i.e. a dog license or per to burn leaves etc.)said person
ou in advance for your cooperation and should You have any questions,
The office of Jnvadgations would like to thank y
please do not hesitate to give us a call.
The Dcpartmaet's address,telephone and fan number
ju Lommmvi lth Of MMWAUSCtts
DqMtWW of Industrial Aocldents
Olds of Invaddadons
600 washia9M Select
Boston,MA 02111
Tel. #617-727-4900 wd 406 cc 1-877-MASSAFE
Fax#617-727-7749
Revised 1-26-05 www MM"Ovlolls `-