63 PALMER ST - BUILDING INSPECTION (4) EOM 1
PUBLIC PROPERTY
C %✓ /-, � —,c DEPARTMENT
We
K1%Q* "DIUSI:OLLL '.
%IAYOZ:: ^ ' 120 WAwINcmN SneEi 0 S,Ys,%L%AACHLSL1-M 01970 j
1EL 978-74S-959S♦FAX 978-740.9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
Property is located in a:Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land I _
Name:
Address: Pp"�aox 3bYGro��"
Offm J e-
Telephone: =L12— a " a4 93
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing 3C
Renovation Number of Stories Renovated
Change in Use 4 New
Demolition Existing rY
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
k�e-
rvcsw Ja` t
Mail Permit to Inx9 0194,E
What is the current ussee of the Building? �"S�dlewh
Material of Building?y.,y -'-��- If dwelling. how many units? y
Will the Building Conform to Law? 1/G Asbestos? ✓{Jt3
Architect's Name
Address and Phone 1
Mechanic's Name '4 NN A/-471�
Address and Phone 49 �AQIZ
Construction Supervisors License# HIC Registration# �/ a
Estimated C f Pr 'ect$_SAX'.G Permit Fee Calculation
Permit Fee$ �'�\V Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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 /� U
Date
� " N
N
F o V v
w T
- - --+� - ------ --
t
92� 'tpamtriw-xue2l� o�✓lLaJxtc�u4¢ '
" Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 131282
Expiration: 6/29/2008
Type: Individual
DOUGLAS M.BROUGHTON
DOUGLAS BROUGHTON
49 SEWALL STREET
MARBLEHEAD,MA 01945 Deputy Administrator
,//ee riomvmmuoea� o ✓�.¢mac�utaeCla i
BOARD OF BUILDING REGULATIONS -
License: CONSTRUCTION SUPERVISOR
.Number: CS 085356
• Birthdate: 04/30/1959 ,
Expires: 04/30/2007 Tr.no: 85356
Restricted: 00
DOUGLAS M BROUGHTON
49 SEWALL ST
MARBLEHEAD, MA 01945 Administrator
`3
it Bedroom 11
( grm Liv II i�I.�
� I�'
0� FT UP ll' n Bath
0/2 a Fnver [r=
Kitchen Dining !1.�u�� "'I
I � I ill--i--�-II Den ( (
4 �j
j I A Ii
I Livingrm ! 1 Bedroom
f I I
I I !
I I I
I
I
I CL ( UP U
I Bath
- -
112
I Bath Foyer
'f
j' UP
Kitchen Dining 1:4=6oml
Den
1
1
f i
j i l Bedroom 11 Livingrm lil I F=]Il Bedroom [11
H
Hi
zJ
';I n Bath
J12
I TP
la
up
1 1 i Kitchen Dining
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aadteatnt t>ttacatt
aLaraa 120 WAaMOMN Suss+a S LD4 M&UACWMM0l9M
TkL 976743-959S a FAM 9W40.9re4
Workers' Compensation Insurance AHidav[t: Bypde WContractonlE edflc ina/Pumbm
Applicant Information Please it Prot r idbiv
Name anal): v� c�1 >d
Address: 4 9 S67t/a-/I2�r5—
city/siataimp: J f a/,4 0, Phoine
Are yen an esFleYert Check the appropriate bon
L O I am a employer with 4. 13 I am a genmal contractor ad 1 Type of project(r"droo:
employees(!an and/or pa t-dme).• have hived the & ❑New eottatrnetion
2..® I am a sole proprietor or gamier. Bated on the attached+heat.t 7. 0 Remodeling
ship sad have no employeaa Thes n have 8. 0 Demolition
working for no in any capacity. workers'comp,mamesce
[No workers'camp insurance S. Owe am a conwation and its 9' 0 Ong addition
nquixot) officers have exercised their 10.0 Electrical repaiea or additions
3.0 1 am a homeowner doing all work right of euanption per MGL 11.0 Plumbing repa n or add(tiona
mysli[No workerw'comp a. 152°11(4),and we have no
huavanee regala t cmpwy ss.[No work=, 12.0 Roof regain
amapq 13.❑Other
COMP,in
fAny Apennine then chub boat tent vies en out the voodoo below d owing drir.orge°eee;rrbe Hader htbtmdae ttameo�aea.h.adrk tNr eladwk indladea bey r dety as week and tit.hie coma.eeae.acta tide h c d rCo son;trek•ew ealatMr _
etraeere iet heek ae.tuM elhehea as Ann slowingdr ere of do a btoss exa.ra dair woe
am, Policy taartttrlea
'r an an MANAY41'Infaseeralaea that 4provAdlnj wank ra'eowOeawdow/ntrronCefa erg,ewp/oyea Belay Is Ae poAky and joi sAw
lasumnce Company Name AIhSSfPArJ %aivAa�� ��y�,Yl
Policy Nor self-iaa Lie N 4 ^/9Z Expvadw Date: "2— -ig
Job Site Address: 43 a/M 6-(— <fi} Ciry/Stato2ip S�IIUwL jw9
Attack•Copy of the werkan°compensation policy deehnratien Wge(showing the gooey number and exp"tldn dab)
Failure to score coverag,as required under Section 25A of MGL e. 152 can lead to the
fine up to S 1.500.00 andlar one-year' °f�Panama of a
y tmpriaonment,as well as Civil penalties in the form of a STOP WORK ORDER and fine
of up to 3250.W a day against the violamr. Be advised that a copy of this statement may be forwarded to the Ofliee of InvestigWom of the DIA for inomance covenga veri llcadoa.
/do bsnby arayy an/er PaGu afperlwy Ass r6e lefaeeadowOrovMd abaw is&W err/comes
FBoagrde(Health
use OXIA Of am wri&In Ale arse+to he eospk0e,byC4 a town oA&I
wn: Permit/Licesse 8
uthority(circle one):
2. Building Department 3.Cityfrowe Clerk 4. Electrical Inspector 3 Plumbing Inspector
&Other
Contact Person: Phone N:
Information and tnstrUVROM
i s2 Kgnise all employes m Provide worlcas•Oompea�O°for their moploye� -
%,Ua5Whuseaa Geon al Laws cbVear 1 defined "..every Paso■in the service of another under aMY conasct of btt�
Pucwant to Ns sntne,an ass ,
express or m*UA Oral or wntoen.'
aswciaaous.corpoadon of other legal entity.or any two a mat
An sy■PIeY r is fined as"an udtvtduel.Perm ad'p the
1eC1 rePea�a`�of deceased emPloYW.or the
m a joint aterpr+a. employes ddowaver the
Of the foregoing eipded . . p.anceWo■or other Iced entity,empl°Y10` Wave
receiver or anew o[a■indtvWual.o aser s tha and who tesidet t MVM a the occupw Of do
owner of a dwelling bonee�na ersons to do msi�. or renew� wh dwelling
m be
an cOMPJOYW-r
dwellift hOuss of at a ild thereto sbafi not because of tsrch empbyaw
at on the grounds a building;appurrmaat lass" a at
Also were!that"every state Of lead lftxniusg aga■eY slag 90an"withh u tkM
MOI.chapter, erases or pe a baat■ae a to es■Nrud badWl■p 1■tie eosse■walte tar any
renewed ar.tlnw or perslt to ti evidease of cempgaaea why Me Warsaw avarae req°�d'"
applicant ww le(net p ledoseed as"peitler the commonwealth nor way of its political mbelv>�r
�ddidOoslly,M(it.chapter p forma )neg ofpublic work until acceptable evidence of compliance with the ittstttsnee
at into any CMUS
r� eyes ban him presented to tba eooMaedng wtlartY•"
b and'it
Applicants the boxy that apply m Yea�O6
.by cbeclani
affidavit their cati6eamU)Of
comPO° wuh
out the worlcera s along
Pigs" M.contraew(s)name(■),add<as(a!)and phone nu°u with no other than the
neaaaaarY.step!/ (d LC)or Limimd Liability Partnerships
(L�
y wrap. tiuximd Liability ComP!O Renee. If an LLC or LLP does have
aembas err partners.an not cegtnB'reed advised that this affidavit may be submitted to the Department of Iadusa it
employees.a Policy is mot insurance coverage Abe ti.slue to alp sad date else affidavit. The affidavit s old
Accidents for Ooatirmatian P err license is being requested,not the Depataneer
be retoraed to the city at town that the application ding the law or if you are required to obtain•wrorken'
p
trrdusa++l�eleds l m yoo haw any q nnuurmber listed below. Salt-donned compsom should cam their
action conipatspolicy. umb all the Daptntmeot
se�bu,wnce llemee mmber on the tlOf.
CUy or Two Offielar ant has a specs at the bottom
Please be sure that the affidavit is complete and punted legibly. The ons hasDeputn o c
of the affidavit for you to fill out in the event the Office of invadgatioos here m contact you regarding ading the a liffli a
Please be sum m fill is the permlrAieese number which will be used a a rcfaenee number. In davit i a■applicant
applications
in any given yea,need only submit toe affidavit indicating currant
that must submit mtulaple pamttAinanw
policy Whrmstion(it necanaty)and under Job Site Address the applicant should writs"all may
be provided
in.__1he err
town)."A copy of the amwit that has been ofll<cially staotped or numof lieeosaaiced�the city ac�m nost Y MW w cub
applicant as proof dat s valid affidavit is on file for Three permits nk rctated m any business a commercial venue
ear.Where a home owner a citizen is Obtaining. s i license is permit m lest this affidavit.
y or to burn lave em.)said person is NOT
required(i.e. a dog!lase perttut
ns would like to thank you in advance for your coopersuaft and should you have any 4 OnA
The Office otinveatietio
please do not bainm to give us a Olt
The Deperuntmes addme.telephone and fax number.
The Comm vftath of Massed usew
Dquema of lndllattial Accident•
O®a of livadpltt u
600 W8AM91W Street
Baden MA 02111
Tel. #617-727-49M to 406 of 1-877-MASSAFE
Fu 0 617-727-7749
Uviscd 5-26-05 www.mmgov/dis
CrtY OF SALEm
PUBLIC PROPERTY
DEPAIMMEN r
M.VCe ts�wort.,aa�t .:..a.x...oa�ae,sm+t.
„k0&7464M PAStrts.746"
Cons&ucdoa Debris DbIMAt Af'WaVit
(nqe "sx sY amomset sod Wad*
In w md.ms with the 3KpwAslow se*Mnotdwk lei C�780 CUS Leedom 1113
odwK B p is bored vft do mmAdw do the ddwk m ddes 0or
this, eb n bs dtspossd of lu s i WP V i omd now dbpmd fit►s dsdemd by MGL s
I Lt.SIs"
The ddeis Orin be t uvoew br:
(amo of bnMrl
The dads wiU be dispowd o[in:
.f/.nc-&S b� adaQL
(same of rMam o
s;roas,oe otpw�ie�pytias
dw