17 PUTNAM ST - BUILDING INSPECTION II
J �
the It of %Ia.ss•u Iw,eII; -
I Board of Build ng Rrgulmions and Standards t)It
` y 41ass:rrhusrl[s State Building Code. 78U ('11R. 7'' rJi;iotl ! \Ir NI( J! V I : 1
! Building Penilil Application To Construct. Rcpau. Rtnota(c OI- Dctn•.t!i.h II I K„,I„/I
--- 011v- rn' Tuo-retail Dlrrllmt!
Fhis SeLiw; t - —'- --_—'--- — _ For(1Ffitial F.se C)n!v ---,
!i w!Jin� Permit : umhrr- �D:ne :Applied:
---:—. - -
e Cnn :;up_..(I rot flwi img,
.SEI'PION 1: SIT(( INFORNIAl ION
, !r ,s I \lap & P :rrr•I Numbers
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Telephone -
r• DESCkIPT1ON OF "' )POSE C IVORh1 ( he k J; t,:.0 apply)
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ribD '_ (lrtxr Fces: '6
:. %lechaniLal IHVACI .5 List
r . blrchanic:a !Eire -------------1 -----
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- ---
u pre!,_, n) � I Fr rt a Ali Fct,. b 70 C -_�
b Final Project Cotil: 5 ... . heLk "w�,�0 Check :kunlunA/ ! � ( ,,h \m u"nu -- -
_�. UIr - )OPeid ul Full ❑ OwNrmdin, B:d:uxc Due __ 1
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SECTION 5: C'ONSTRUC'rION SF:R%1IC'ES
Q�
F
1 1icensed C,-onstructifun 5upenisor IC'S1_)
—2
: lO U r VY i 1'ense Number — �I'.\pir:wnu D.u:
\anpe of ( SL" IIuIJer l.la CSI_Tx pe Ixe hrluw II'd
1/1C I 'fy r Descn Poon _
WJrcv
R Resulctcd I.@'_ E.uwh Dw clhne
l n: live \1 \t:uonn Unh
HC RaslJenual Huolinc( usciur�_
\\'S HC t&IIIlal \\'u,Jo„ .mJ
f: phone
_ 1p HraJ:uli.d SohJ Fr,el wne
p Ite"Jenl,al Demohuoll --�
5.2 Registered Hume improtftnent Contractor 0110 ---
Reg,strauo❑ Number
HIC Co ntpany Nanle or HIC Reg
lstrant ume
Address �}_ Q S�•z �� Expiration Dat:
l —
/ - releplu,alc
Signaure —.
(�
Sr. ON 6: Wort ERS' Ct)RIPENSAT3Oi� NSUIRANCE AFFIDAVIAFFIDAVIT •G•L_c. 152, g 'SCtfi))
F:ulure to proslde
Workers Compensation Insurance affidavit must be completed and submitted with this application. ,
this affidavit will result in the denial of(he Issuance of the building permit. _.--
Signed Affidavit Attached? Yes ..........
No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject proper(}' hereby
to act on my behalf. in all maven
i ;tuthorizr _ I
*S, U,e�,L�o
authorized by:his building permit application. Date
w er
SECTION 7b: OWNERI OR AUTHORI"LED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
I.
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
I behalf.
Pant Name
Date
SignaWre of Owner or;\utho r,zed Agent _J
ISi tied uudcr the pains and enaltics pf Oerjuryl
I, An Owner who obtains a building permit to do his/her own work, or an o,cner who hires an unregl'let contra.Inc
has'e access to the arbitr:u ion
(not registered in the Home Improvement Contractor (HIC) Program). will nrt
program or guaranty fund under M.G.L. c. ly'_'A. Other important inti,rmanon on the [I[(* Progr:un and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I I0.R6 and I I0.R5. respectiscly.
I When substantial work is planned. pnnlJe the intiprmation nolurbel garage. finished basclnenuaittcs, decks or porch'
Total floors area area
I(Sq.
Sq.
Ft.) Habitable room count
Gross living area ISy. Ft Number of bedruilns _--_----___
Number of tireplaces Number of h.11t/bwhs __—_--_---'_--- ---- "—
Number of hathrooms Number of deck) porches "-- ._-- __-- ----
fcpe L of heating system
f.ype of cooling system — —_—�
'loud Project C'ns('
1. "Total Project Square Footage may be subsututed for "
s�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�lorkrrs' Compensation Insurance .111,14(laxit: Builders/ContractorsiElectricians/Plumbers
) iltaant Information rr Please Print Lr ifl my
N.1111� Jiu.rtc.. t h__amtall�m In.11w dual): (nJ Avl
VIvlflss: /I{ Ikgtl
�('It 5t.lteZiPnt & ✓/ Dt4as Phone #:
—
\re sou in employer:' Check the appropriate box: Type of project(required):
employer w ith _-�__ 4, ❑ 1 till a general contractor and 1 n. b,New construction
have hired (he .ub-contractors #
cinplayces (full and'ur part-nnlel. 7. ❑ Remodeling
_'.❑ I ,,it a sole proprietor or partner- limed on the attached sheet. •.
,hip and have no employees I hcse sub-contractors ha\e S. ❑ Demolition
working fllr me in any capacity. workers' comp. insurance. y. ❑ Building addition
(No workers' comp. insurance 5. ElWe arc a corporation and its 10.0Electrical repairs or additions
required.( Officers have exercised their
ri 'bht of exem tion per N1GL 1 1.❑ Plumbing repairs or additions
}.❑ I am a homeowner doing all work P
Inyself. (No workers' comp. C. 152. 31(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other
comp. insurance required.]
•:illy applicant that checks bus NI moat also till out the section below,hawing their workers'compensation policy information.-
' I lonteowners who submit this altidavlt Indicating they are doing all work and then hire outside contractors must wbmit a new affidavit indicating such.
(',nnractors that:heck this hos must anacheJ an addalonal short showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer drat is providing workers'compensation insurance for my employees. Below is the pu/icy and jab site
injarma/ion.
Insurance('ompany Name:
Policy q or Self ins. Lic. a: Expiration Date:
Job Site Address: u �v7ro ll &� A.7(- City-state/Zip: ( Lo.t-
.\ltach 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
line up to SI.ioo.oft and'or one-,year Imprisonment. as well as cis11 penalties in the form of a STOP WORK ORDER and a line
of ,it to l_250(III-1 day against the I.lolaror. Be ado Ised that a copy of (llls slatel"c"t Illay he forwarded to the Office of .
Iry c,n_,u lolls of the DI:\ for insur.ulce cowcrage wcrilicaiton.
l Ja herehy�ry•'�\n, i/i'o"d-e^r(Ir'e�puin.s Slid pena6LLw aJ perjure that thr ut/ornwttnn pre"ided,21 a is true ant/L orreL L
iiyi.dur• V' nr a Dare (�6,
tl/Jirial the onll•, no nut write in the% area. to he ramplered by r:ity nr to ten off) iaL
( its or rues n: _._. ..—
[.suing \uth oril (circle line):
I. Board Ill licallh 2. Building; Depirinlent 1. ('fit,Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -- ------ _._
('nnlact Person: -- -----..___-- Phone q: ._—...--
Information and Instructions
\Vinj,4u,Cus wncralI .its,chapterI �' Icquuc, .ill cmplu,ci, it,pratideworkers' c,nmpcn,auon for ihc:rengslotces.
I'm'ti.wt no (Ills .(.lituc. .ln emploiee I, Jcr_X,:,l is ' ct ere pcnon in the sett tic of amaher tinder mart ontracf ;If It
:y'1,11 Or :nq,l tc& oral or I%r nen
\.: .veyrl,,err I, Jc 11 tied .Is ".ill :nJn:Ju.J. I ,u m.cr,b ip. a,,,1,is n on. .urpo rat nut or ,Ill cr 1i_al mutt. or .in two or more
,.t the ilia front cntclprnc. .uld ulclu,ling tee IC_al repn•scntant r, ofa JC,eased cuhpl, rr. or the
cn cr or tru,icc of.in uid,%idual. p.uincr,II p, a„ociatwn „r other leg.iI emit., cmplo.�mg cnghlutcc., IIuwcter the
„•.t ncr of .1 'Ittclling house het me not snore than three .Iparinicuts and Ltho ic,nlc, thcivin. or the occupant ,rt the
,1\%ci!mg II„u,e of.Mother who cnq,lot, peron, to do nlauucn.mce. Construction or repair work on ,iwh dwelling house
,.r .,u the _ioands or hudding .iliptuictt.lnt ihcleto ,hill not hc:au,e of such cmplut ownt be Jecnted it, he .in cnlplo}er.
\1(d. :11,gmer I i" ;'K(n) also ,file, Ilia( 'e%ery ,fate or local licensing agency .hall ss iehhuld the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth fur any
applicant who has not produced acceptable es idence of compliance with the insurance cuxerage required."
VIditionally, .%IGL chapter 1 S_', ,,2i('I-) st.ifes '\clthcr the conunontvealth itor lily of us political subdtvl,ions ,hall
enter Into an}' contract for the periminince of public work mull acceptable et IJence of Cuutpliauce w uh the Insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation atfidavit completely, by checking the buxes that apply to your situation and, if
necessary, supply sub-cuntractor(s) name(s), address(es) and phone numberes) 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 nut required to carry workers' compensation insurance. If an LLC or LLP dues 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 atfidavit 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
,elf-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
'It file atflLlavlt for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be afire to fill in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple pemhivlicense applications in ❑ny given year, need only submit one affidavit indicating current
policy intiorrnation (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 pruut that a valid atfidavit is on file for future permits or licenses. A new atfidavit must be tilled out each
}car. \there a hurtle owner or citizen is obtaining a license or permit not related to any business or commercial venture
(I c. a Jog license or permit to burn leases etc.),aid person is .NOT required to complete this affidavit.
Ilse t mice of Intestigaiions trould like w thank you in advance for your cooperation and should you hate any questions,
p1c.1,e do not he,lrate tit gitc us a call.
I he Dcp.utnwri s address. telephone and 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
r
-S 'k CITY OF SALEM
'1 PUBLIC PROPRERTY
i'
DEPARTMENT
'.I I_ A \,IIIN,,IN S!3H r • }AI I M, \1.\,i\, ,li ,l 1 . _1'r _
Construction pebris Disposal Affidavit
(reLluired for all denioIition and ienov Lit ion work)
In accordance %,,ith the sixth edition of the State Building Code, 780 C141R section 1 1 1.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit it _ is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debt-is will
be transported by:
(name ut hauler) -
I he debris will be disposed of in
WO_ .y- (Q'
n �n (name ul laclnty)
--- 9Z/I
jnJJress u(lucility)
—_- ,iermturc,rf panni[applicant
,late
MAP l � � l�oi z � �
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CERTIFICATE OF OCCUPANCY C-
LOCATION: Pc l OA VA >I DATE J U�1 �:T2�U O
APPLICANT:
ASSESSORS
FRANK YUU'r DATE: t; 0
(93 Waahinpon Street)CITY CLERK
CHERYL LAPO DATE:_—�7�T D�
(93 Washington Street)
(&tv1FUBLICE SERVICES. DATE: LN P
(1.J Washington Street)0 Floor /// 'L / _ �� 1"•
WATER � �
DOTTIE THIBODEAU y
(120 Washington Street)4*Floor gg� x p
CROSS CONNECTSUPEF� //r� ATE: � UU
BRIAN THIBODEAU
(S Jefferson Avenue) ' /O
PLANNING DATE: b b
12ti Washington Street) 3
CONSERVATION COMMISSION
DATE:
(120 Washington Street) 3 e F�ooru —
ELECTRICAL
JOHN GIARDI DATE:
(411 Lafayette Street)
FIRE PREVENTL/ DATE:
ERIN GRIFFIN
(29 Fort Avenue)
HEALTH ,
JOANNE SCOTT DAB' O
(120 Washington Str Floor 0 Scweu ``! 14"a
BUILDING
THO`IAS ST. PIERRE DATEc G 0
(120 Washington Street) or
i
m- mm
1 01 ,1111 RIII 11 11 mil 1111
Fff
' ® FF mmv:
FRONT ELEVATION
SCALE:1/8°=1'-W
If=7
- - 63.0'
� I
/ w
x
N I
LOT "A"
/ 4,550 SO. FT.
W ESTRAYA DUEST
y & I
JOSEPH GIBELY
Lu
h I
Lu
I u~i
/ f
HOUSE #15 I F
77.78' _ _ _ -
36'-0,
I
I^ LOT "B"
2,220 SO. FT. o
IN ROBERT GIBELY HOUSE #13
& N
JOHN DRINKWATER
I
w
N - - - - Mesa' - - - - -
VARNEY STREET
SUBDIVISION OF LAND IN
SALEM OCCUPIED BY FOUR
LOT PLAN
APPROVED__ ��-
Subject to approves by any other
authority.hang jurisdiction.
CITY of SAUM,MASS.
FZFW nT'REVF.sU"Ll"I�3 BUMIAU
EY
PLANS ARE APPROVED SOL FOR t0ENMF!C.VI CF
TrFE AND LOCATION OF FIRE PW;CU'M C /:C=S.
ALI. FIRI-PROTECTION DEVICES."...^.E C 3Jwi'TO A
':1f M1L IlJI Am iv,]rCu I lull. v.rIr1LIC VIMf
nnr
36'-0"
14'-0" 6'-0" 8'_0" 8'-0"
-----------------------
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U0
o q
-------------------
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- - Q
STORAGE co W
--- - -- 26'-4"X 22'-4" x
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Wed
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SCALE: 1/4"= V-0" ]
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36'-0"
31'-0"
10'-0"
w J17
❑ D
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DECK o N x
olu O �0'
OPEN TO BELOW �Q V4 LIVIING ROOM W
0 24'-10"X 11'-6" z F o
10'-0" 'v Q W
12'-2" 13'-0" S'-O"
04
FIRST FLOOR W
SCALE- 1/4"= I'-0" ]
Op
w
36'-0"
w
c !�
WALK IN Q
m BEDROOM 2 CLOSET
10'-0"X 13'-9"
_-------_-
p � x
Q MASTEROM �}
11'8"X 12'-6"
DECK SITTING AREA
8,0"X 8'-0" 8'9"X 10'_4"
BEDROOM 1
8'-8"X 13'-6" Z F� o
C O o0
QW �
. 1:4o
Q
SECOND FLOOR
SCALE: 1/4"= F-0"
aq
APPROVED �_
Subject to approval by any other
authority havia9k4ris i5U0ZU
CITY of SAIZM, «?t'.a33- �y
�6 ¢ Co
BY 140%0 4.440R ApaAa%
PLANSAREAPPROVED3KE •tDEf,"I".l.Ji J.:
s FE AND LOCAMN OF FIDE pFO'4=`�'T"?7
WITFI THE FIPE COD -
36'-0"
14'_0" 6'-01. 8'-01. 8'-0"
----- m T
1--I
Dew -----------------------
Q
STORAGE 4! W
-- 25'-4" X 22'-4" -----------------------
o x
N r�
v
�I'vQa
ENTRY w
p
----------- ---------
Q Quo
w
xzw
SCALE: 1/4"= P-O"
0 �
Pa
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36'-0"
31'-0"
10'-01.
w [E
KITCHEN/DINING cO cn
--------- 20'-10"X 11'-6" Q_ Down
❑ D
� o
DECK + N W
I 'EL
� O
OPEN TO BEL LIVIING ROOM w
o - /� 24'-10"X 11'-6" m O U � o
z
w
10'-0"
� H
12'-2" 13'_0" 5'-0" w rn
FIRST FLOOR w
SCALE: 1/4" = P-O"
O W
pq
36'-0"
0 Fy
0
= � o W
F WALK IN ^
m CLOSET V-I
BEDROOM 2
�10'-0"X 13'-9"
M RBEDROOM, �}
qI X 12'-6" UO
DECK ®SITTING AREA _
WO"X 8'-0" 8'9"X 10'-4" p
8 0,
BEDROOM 1 W
8'-8"X 13'_6" Z E� o
N
SECOND FLOOR W
SCALE: 1/4"= P-0"
O P.
0.
-rldr.764; has, 2-
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l�Gf2�� FLF-vI3-��� s
fiT 14M77
97zM7 Pa�fii��
2�� ST'opaEs l �S� is lb.
gig
'4 kVAwt 62IY1L4�.-
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