95 PARADISE RD - BUILDING INSPECTION �• 9 `City of Salem Ward
U ` APPUCATION
FOR
PERMIT TO BUIL DITION, MAKE ALTERATIONS OR NEW CONSTRUCT
I PORTAW-AppMcwt to complete r h1wim in s ermn. 6 K t4 IV. and LT. p��q
L ATILOCATIO00 '✓ �'�'ti- X4p OISfRICf
LOCATION
OF 9Er*FFN AND
BUILDING lobes STRMM ,moss STra"
9u8OM90N LOT
LOT BLOCK 912E
R TYPE AND COST OF SUILDINO -All aWlcants complete PWU A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOUTKW USE MOST RECENT USE
1 ❑ IMP OLAdWo Reef , ,
2 ❑ AAdMm(M msidw*K w W rwrtbw cd nw 120 Or%n*f 19 ❑ AMUMPAnL raoenbrW
houSkg urtlb adda4!any.n pwr a 13) 13 ❑ 19 ❑ Ondl, raHOMM
3 AI m -1 1(SW 2 above) cd unrAntole 4aNy-Enrr ntsnbr 20 ❑ kwuMr
40 Rp-&mplaarrrrs /a ❑ TIwMM ho1K rt1oY1,w dbmeklry- 21 ❑ Prkkp gaga
Etter numbr d unfd_ 22 ❑ Swviw xWftm.spay gr*W
9 ❑ `MacknO M dAAV I P nae d 13) «. tomb. 23 ❑ HopML WOMAIMW
d unit n.bu efyq h Pa t a /3) 1S Q OsraP
9 ❑.Moving(nbadcn) 2+ ❑ Pub.brill plelaaalernl
1e � Crpert 2s Q P1e9cJiy
7 ❑ FP`sxhdbn pray 17 O COW-SOW* DO AK\it 28 ❑ 9dWA anry.odw educadpW
S.OWNERSHIP 27 ❑ 31oraA m.lvess
9 ❑ P&.08(ndiv dual,cpporaltorl r p 111 28 ❑ Trtly W~ls
InepNloe,Mc.) 29 ❑ Odr-Sp.&
9 ❑ Public(Fedrr.S%ft.nal{ptamnynl
C. COST 10"*ow" Nrseaidrwsl-Deembe n deW plapowd ur d busdinel ea.kwd pocsaa010 Plant
/�j p. ntadlkr etkW kastdry buk"al Ilpap1,K Willt=*my whad seoadrych school, a2 oose
is rtppwochkil Cord. rotrertwy /✓' Ave.v-- at rxk*&bl pair+.MF1*us*of a�g�Inb"V NrbgK.rr aposse uulla dk�-;
To b•kaft0ad but nd kv*m*d
:n dta more cost
a. Ekactrical .-----.........M> o m.i2... --
s
a Pti,nw,a .._.._.._._.. on a -7'� cc u i�IK i n � vt,J%S
c Headna air condWorwV..4TO&Cc?.-._--
IPPJNCIPAL
OST OF IMPROVEMENT Y✓�
TED CHARACTERISTICS OF SIALDING . For new buildings and additions, Complete Parts E - L.'demolition,
to on Pats✓6 FPRPX
o IV
AL TYPE of FRAMEOF NEATPq FUEL G. TYPE OF AGE DISPOSAL L TYPE OF MECHANICAL
".y ttvr beanod0 Pubrw v p,ft oonpsny- •Xr M"be a 0*w
fmd frame s1 ❑ Pnwr(aeple buck.or—) m+d%'61.cytaal skMl wey as o ❑ '6-0c1ed cCnvels K TYPE OF TER SUPPLY
WiD oy an elevalo!!w SoecM -Sow.V 42 PtA or prat ooetpany yM 47 s
i K /� -- 43 Q Prlvals twA cimem)
r �-
E
J.ooE,rsaw M. DEMOLITION OF STRUCTURES:
as Nmder of sC(ee ._......___._-. ..__.. _.. __... .
as TOM,a,,,,r fee a roa uaa Has Approval from Historical Commission been receive
r me cr+b W urov for any structure over fifty(50)years? Yes_ NO_
snrrw - ._...- __
s0 Tar and ere%as it 5 - --- Dig Safe Number
K.nKt am or oss-srnErr vYaWa SPACES Pest Control
St Errloae0 .__......_.-_._..___...... -_......_.____.___
HAVE THE FOLLOWING UT1LfT1ES BEEN DISCONNECTED?
52 OkAd=M._.___..-- ._._.........
Yes No
L RES111Br>�s mci uan Of" Wetr:
f]ectria
sa Ercloesd ...__._.-- --- Gast ;
fW----- ----— Sewer.
54 r'aa"Oer a1 DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
°i"VOa'w vner .__._.—..._...._--. BEFORE A PERMIT CAN BE ISSUED.
N. COMPLETE THE FOLLOWING:
Historic District? Yea_ NO_Z�(M yes.Please enclose downigntation from Hist.Corr )
Conservation Area? Yea— No-!f!f�'(H YM Pose enclose Order of Conditlons►
Has Fire Prevention approved and stamped Plans or applications? Yea— No— 1�1 1ST n
Is prop"located in the S.RA district? Yes_ No v
Comply with Zoning? Yee_Z No (t no,enclose Board of Appeal decision)
Is lot grandfathered? Yea_ No H yes,submit documentationM no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yea— No— -t/
Is Architectural Access Board approval required? Yes_ No_ (If yea,submit documentation)
Massachusetts State Contractor License S C58��/ u Salem license r
Home Improvement Contractor i Homeowners Exempt form (if applicable) Yes_ No—
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6) MONTHS OF ISSUANCE OF BUILDING PERMIT
5 t an extension is necessary,Please submit
CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings
V. IDENTIFICATION . To be completed by all applicants
V�q ad Uves %ruder,sear CO.and srre ZIP Code
Ergr. G'GYiJ�'/✓i/'' C
I hereby certify that the proposed pork is avth0^zed by die owner of record and:mat I have been authorized by the owner to make this application 7
as his authorized 3WM and we agree to conform to at licable laws of this;urisdiction.
Application date
Sigrature of applicant Address
i
t �
DO NOT'WRLTE BELOW THIS LINE
VL VALIDATION
FOR pEpAgTAIENI'USE ONLY
Buildup
Pertnil number use C' o
Building
PerrtM issued ell Z� Fm GmmnO
M" /3 8o ur.
Fee S O y LDW
Certificate of 00cupancr s A pfpVed
Drain Tile /I�-..,
-
Plan Review Fee s r A�% (L4 SIVO
NOTES AND Data• (For department use)
d
C
'iAJSe. Gm "d
S
t
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E
i 4 JJ
PERMIT TO BE MAILED TO: 41hp�Is G
DATE MAILED: �/� (s�O ' ®QqV e �
Construction to be started bY. Completed by
E
4
l
t
i
h ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES"
SITE OR PLOT PLAN-For Apok"Use
ON
_CITY OF SALEM
PUBLIC PROPRERTY
(Ioz
DEPARTMENT
i
\I'.1. K I-': Ill, Ni) 4 S.%:• N, \t."i.N
'FI-. '�,'It-��Y')i95 • I'�x: ')?dJ1;.9d iG
Construction Debris Disposal affidavit
(required fur all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit N _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by M. GL c
111. 5 150A.
Tile debris will be transported by:
—. _._��LL�t[I
I he debris NvIII be disiosed of in
1 a.+c:e.,i laai�dy)
V
.:f
-- 'CITY OF SALEM
PUBLIC PROPRERTY
au �� DEPARTMENT
�:Vltl hlI '� I'H lit �tl I
AC'y, l:N',,I,a%]I!'i I I I • y.v1I V. A1."so 1 :s .1'I
11,1 : )-s-, t;.•;;•); F rx: `)-N-'i:-A4,)
Workers' Compensation Insurance Atlida-,it: iiuilders/Contractors/ElectriciansiPlumbers
t the ant Intn-niation Please Print Legibly
�i;llllc I Ruslne.; t trg.m`laiti,�n Indn.,luel jaw
:\rlrlNSS:�� //JJli`'ldhdot, �45Z_ 7 --d" "✓
C'ity,Stitte'Zip]�yfi�td�`� �� s �'� Phone #:
Are you in employer:' Check the appropriate box: Type of project (required):
I.❑ I :un a employer\with ;. ❑ 1 am a general contractor and 1 6 ❑ New construction
tployees (full :md)or art-time).` have hired the sub-contractors
p '. ❑ Remodeling
' I ",ita sole proprietor or partner- listed on the attached sheet.
ship and have no employees I-hese sub-contractors have S. ❑ Demolition
i workers' comp. insurance. y. building addition
working for me in any capacity.
No workers' connp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] otticers have exercised their
right of exemption per NIGL 1 L❑ Plumbing repairs or additions
J.❑ I :um a homeowner doing all work c�152, I d ,and we have no myself. [No workers' comp. � ( ) 12.❑ Roof repairs
insurance required.] f employees. [No workers' 13 ❑ Other
comp. insurance required.]
';\uy.applicant that cheeks box AI mint also till um the section below showing their workers'compensation policy information.
' I lonmuwncrs whu summit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�(bntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp policy information.
I um its employer that is providing workers'contpen.sation insurance for my employees. Below is the policy and job site
infornunion.
Insurance Company Name:
Policy k or Self-ins. Lic. #: Expiration Date:
Job Site Address: Ciry/State/Zip:
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 lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.01) andior one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to )'-50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Im c>tic:uions of the DIA for insurance coverage \crificatiun.
/du herehy a erlil ,tiler the pains and penalties o/ teri.ury that the information provided th is trite and correct
Dat `Y/," �/ �
\l"n'tfltre',
Ullirial use und},. Do not write in this area. to be rumpleted by city ur lawn official
Citv or llnsn7 Permitil.icense
Issuing kuthority (circle one):
I. Board of Health 2. Building Department }. City/l'own Clerk 1. Electrical InspectorS. 1'Iumbink Inspector
6. Other _.__------
Contact persons_____----- .——_-- Phone it:
Information and Instructions
\Lc sae hu se us Grnerd Laws chapter I i' requires all cmplovers a,pro%ide workers' compensation for their cnhplovccs.
I'••lr.;u.tnt to this >tatutc, an rinp!✓ere is defined is "_.clew licr.on in the sell iec of another under anv contract of hire.
,.Vlc<s or implied. oral or orirten."
\n rutplu err is detined AS ":m Ind:\:dual, p.trinei as:oc rotor. corporation or other legal em a it}. or ny hvo or inure
,q the thn.•going engaged in a joint enterprise. and including the Irgal reprc•Srntati�es oil deceased employer. or the
rce o civcr r trustee of:m mdividuul, partnc•r.hip, association or other Icadl cut:ty, enhplo%ing employees. However the
,,.%ncr of a dwelling house havine not more than three apartments and who resides therein. or the occupant of the
,h%tilling house of another who cnghlovS persons to do maintenance, construction or repair work on .uch d«elling house
o1 nh the ,rounds or building appurtenant thereto shall not because of Such employ ntcnt be deemed to he :m employer."
\I(if.. chapter 152, 2;CI R) 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, \IOL chapter 152, i25C(7) .tates "Neither the conunonwcalth nor any of ns political subdivisions shall
enter Into any contract for the performance of public .vork until acceptable evidence of compliance with the insurance
requirenhents of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s), address(es) and phone number(s) along with their certificate(s) 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
Ile 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 he 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 he sure to fill in the permiulicense number which will be used as a retcrence 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) and under"Job Site Address"the applicant should write "all locations in (city or
town)." 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 the For future permits or licenses. A new affidavit must be tilled 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 burn leaves etc.) .aid person is NOT required to complete this affidavit.
The (n icc of Investigations would like to thank you m advance for your cooperation and should wu have any questions,
please do not (hesitate to give Its a call.
I he Dcpartnhent's address. to lephona rind tax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia