7 RIVERBANK RD - BUILDING INSPECTION .
fL�116Mi�!'iit9EfiL{'��ND 1�DYED 8Y TiiE
�,u�oFr_rcv���p�TDA.PEA1�17'�EING GRANTED
nw.�S✓� � CITY OF SAI.EM
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BWLDWa PERWT APPUGTION FOR: ,
Pormd w:
(Clrola whioFwvor apply) Roof. InrWI�������C�n�n�ct Dook. StNd. Pool.
. Olh�r' o r nn 2.�
PLEASE FILL WJT LEGIBLY i COMPI.ETELY TO AVOID DELAY8 W PROCESSMrti
TO THE INSPECTOR OF BUILDINGS:
Tha u�rsiyned herobY ePP� � 8 P�� to bufld accordinp to the foUowin9
sp�ific�►ions: -
Owners Name ���l�r/!��✓ ���''��'
Address & Phor16 7 �r�✓�,/4G1/I /� Y`i�, j ��1 7�� " �/��
M�hiteCt'8 N6me �a J i�l\ �A 9�r 7`'`--
n�� a Pn«,. $�no� sfi. ��-fv l 9��i 9 2 7� �s� �
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Address 8� Phone 1 �
ww��.a�purpa.a ararq7 �'(Ca{�'_ a ���oo�-�- V�a �
MrwW a buYdinpT I���o�, q a dwr�Wrq,br how m�nY I�n�s��_
YY��IdYq oontorm b InwT �/�'S Mb�qos4 ��r�
Erimwd ooat 2�O o o q�y�ioriw�► N A Sow uo n� •
���/�x Ya�. LPro.rac
V Lte. /
Sipnaw�a of Applicant
s�u uNOER n� �nr
oF�ruRv
DESCRIPTION OF WORK TO BE DONE
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I � Thc Con�mornvedth ojMassocnase�r.r
�epurtment of IndusMd Accideets .
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6Q0 WasGingtos Si►at
Bostoe,MA 02111
wwwuhosssoi✓db
Workera'Compensatlou Insurana Aflidavit: BviWers/Contnctors/ElecMcians/PIuL�b
se rint e¢i ly
p lt n informatio �
Name ' � � '
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naa�� � �2; a��� ha� � �� �
. �n . or47o ����: 97a�-- �f��- ���3
City/$rate/Z1P: ��'�G� r
ell CLeektYr�PPi'oY�bO10 '1�P�d projed(n9d��)�
I Are Yo�n emp�a9 4. � I am a general coatrxror and I
1.� I am s empbya widi 6' �°0� �
cmpbYoa(8�Il aad/orPa�t�eb� have hued�e sab-oo�aclon � ���
listed on tLe atlached slwet=
2.� 1 �m a sole pmpnetor u*Pa�ma- Tbese sub-contracoon have s. p n�ua�
ship�na hava no emPloYa+ . v„urka,� comp.ms�uancG g. p gu�7ding ad�Uon
worldn6 for me in anY caPB�Y• s. 0 we are s coryoration aud ib •
IN..�pf� �'� otficere have exacisad their 10.�Elanical nPass or ad�
� of exemption Pa MGL 11.� Plumbm8 r�Paas or additiom
;. I am a homo�n�doin8 all work T�
, , a 152,�1(4�a�we havt no 12.Q Roof repauti
�1£ [Nlo worken �• b aa. o wofkus'
��°d']t co�mp��Q��l 13.0 Other -
'AnY�PP��tEd cheeh bmc Ml amR�Lo 5ll out�e eecdon fieb.nw��en�' �hacto,m m�A wbmit.�on'�davit iodicatina such
Ii}[ameowvm�atio�hfmt Pob etBaavit�i m0Y �i
� tC�pKpe ffi�t ehak tffi box m�t etOeeLed m dditiond ahxt e6owvmi tfie ame of tbe abconhktas md&eir wmEen'cart4•Po*Y mform�ao.
I aw a�es+plo!'a du�t v provldind
worksn'eompensadoe l�uwnnes ja+�'tt�nPloYus Bdow l�dYs po/ley�»lJob sl�t
tRfore�doR
Insutance ComPmYPlame�
Policy#ar Self-im.Lia#:
Exp'vation Data:
City/StatdZip:
Job Site Addrds: nnmba a�d espiratlon date}
Attaeh a eaP7 of We Morturs' compenaatlo�potley dalantlo�Page(showdna the polley
F�m y��,�ge ay T�quircd yndar Section 25A of MGL c. 152 can lead to the�posi�n°f cr�1 P�ti�of s
�' as well as civ7 paaltles m the fotm of a STOP WORK ORDER�d a fin°
i fine up oo SI,SU0.00 md/or o�y �
of up to 5250.00 a day agaiaet ihe violator. He advisod iLat a copy of tLis staument maY be focwazdad m tLe Office of
im�estigatam of the D1A far msu�cce ooverag,e vaiHcatioa .
i ro n.nfs« r� �a�o ojv�•1•�►y rti.rr�,s�f�v�ue�.bo►�e rs aw o�ce.►+eec
i D �
nlu,n�f1 / / �� / ! � '�/ 0� �
- - D�CW fLf6 OR�ji �0 lld MY/if�l�f fIl/i l0 bl tOA1�L1�bJ��'OI JOM�O�C�
City or Tow�r: rermWL�ame M
Iuat�t AuthorNl(�one):
1.Board o[HakY Z.Bulldtng Department 3.Cky/fows Clert 4.Etedrleal Io�pator S.Plambing Impector
6.Other
Co�aet Perwe P6oue N:
1111V1 illfibiVii fiiill �i11061 {1�.61V11�7 .
Massachuseda Gweral Laws cLapta i 52 requirca all emplayas oo provide workas' coa�ensadon tor their employas.
Pursuant to cLis stamu, an e,wployer is defined as"...every person m t6e servia of wotLer unda aoy contract of hire�
�or m�plied,oral or wcitoea"
An LIIIQIOyQ ffi dCSGOd 8s�80 I�IV1d0iI�P9I�CdSbIP�84fOC181�Cptppl�LOL Oi 01hQ 1C�CCMY.�8LL�lW0 Oi IDOiQ
of tLe tore�om8 rnga8ed m a jomt ea0etp�iee,�d�ludmg the legal npresataaves of a deceasad euQloyer,or tbe
receivc��sta of an iadividwl,P��P.association or odur kgal entitY,emPbYIDB emPbYea. However the
ownc of a dwell�house bavint mt mon than throe�aod wfio residea thaeie,or the ooa�Ot of the
dwellrog Lousc of another wfio a�ioya Persons m do mamteoance,conswcmn a�npaa wort on sach dwellmQ house
c�on the gro�mdt or Du�7dio�apputten�t thaeto shaD mt boause of snch aupbymmt be damed b be a�eo�bya.•
MGL ch�pta 152,§25C(�also staus tEat"every pate or loal&enaie=ageuy�Yall w�Ite�oM tYe la�ane�or
rmewal o(a tleee�e or permlt to opente a badun or W eonttnd baltdlep i�tYe eommoaw�aMi for uy
apptlea�t wYo ha��d Prod�ed aaeptable evtdnee at eompNaaa�vN�t6e I�arua covva�e reqdred."
Additionally,MGL chr�tu 152,�25C(n atatp"Nei�u the-commo�veat�mr any of ib political�ione abaII
e�a mto soy contrxt Sor t�pufoimance ofpubHc wo�anul aoceptable evidence of oaq►lfaax w66 the mauranoe
rcquaemma of thie cbapta bave bem presented to the co�actio�antLority.'
APPHeub I
PkS9e Gll out tLe wotke[e'COmpenBatioII at8dsvit comPu0e1Y,bY checkmB tLt boae8 tLat apply b yaut SiO�atipn god,if I
n�Y,�PPh'���s)n�($b�(ea)and P���K$)�8 with theq ccd8cate(s)of
inauranca L�ioed Liab�7itY Compaeia(LI.C)or L�iOed Liab�7ity Partneishi�(I.I.P)with no e�loyea other thm Ure
members or parmaa, are not ralntted Fo canY wo*ken' compensaeion ms�usnoe. If an LLC az LLP doa Lave
�P�oYa+,a poficy is re9uaefi. He advised that dris af6davitmay be submiued m the Depasdnat of Ind�ial `
Accidents for confirmatioa of ms�uan�x oovenge. Alw be sore to�p and date the aAldavlt. The affidavit shoald
be rewrned to the city or oown thst the appliatioa f�the pamit or licenee is bemg rcquested,ad tLe Deparunent of �
Industrial AccideWe., Should yon bave any qaesaona regand'mg the law m if yoa are requaed�o obtam a workeas' I
��e�Po�Y�P�call tLe Departmtnt�t 1�aomber listed below. Self-ins�¢ed oompaniea slwnld mter thev
self-insur�ce fiaaae mmber on t��prapriale 1�
Cky or To�ra OfAelab ,
Ple�e be s�ue that the affidavit ie oo�lete and prmted lepbly. 1Le Depaument bas.provided a space at the bottom
of tLe af5davit tor you to fill ont in 1Le weut d►e Ot�ce of Investigations hae Lo contact Yen rega�d'm8�aPPlicant
Please be sore m fill m the pamiUtice�e�ba which will be used as a refueuce wmber. In addidon,an applicant
that must submit�iltiple permit/ticense appticatione m aay given Yen,need only suymit one afHdavit mdicating current
I policy mformation(if�sary)aod nader"Job Site Ad�eas"the applicant slwuld write"all bations m (cuy!or
mwn}"A oopy of 1Le affidavit tLat has ban officiaIIY smmped or,marked by the city a bwn may be piuvidad m the
appHcant as pmof tLat a valid afBdavit it on 5k far l6mn pem�ict or liceosa. A new af5davit m�st be fitled rnrt escD
ye�.Where a home ownu or atizen is obtimio�a license or permit not relatod to aoy busmee�or o�mmencial vadne
(i.a a aog licenae or pamie oo boin kava eoe.)s,ia pasoa ia xar ttynn�ea to compleee rms affiaavit
' The OtSa of Imestigatiom would I�l�e oo thaOt yon in advance f�yo�coopuadon aod sLonid yoa have anY 9���,,
pkage do mt h�to�ve ur a call. •
The Deparm�enYs addnu,telePhone and f��: �
The Commonweatth of Massachusetts
Depa�neM of Ind�hial Accidents
O�ce of InveatlgaHoni
60o w��con s�c
so�n,Mn oziii
TeL #617-727-4900 act 406 or 1-877-MASSAFE
Fax#617-727-7749
xev;sad 5-26�os www.mass.gov/dia
� � CITY OF SALEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
I20 WASHING70N STREET, 3R0 FLOOR
SALEM, MASSACMUSETTS 01970
STANL[Y J. UtOVICZ. JR. TELEPMONE: 978-743-9393 E%T. 380
MAYON FAX: 978-74Q-9e4a
HOMEOWNER LIC'ENSE EXEMPTION
Please Print.
Date /� / .o
� Job Location � 7 i ve ��ai(� �
Home Own�Addrose. k i ✓ r ati .
Home Owner Telephone 7��.7�f`I �S 1.g3 ,
Present Mailing Addnssr;. ��:. :�
The current exempdon of"Homeowners".wae extended to include ownar-occupied
dwellings of twaUnits or lese and to al]pwr$uc�hqm��q�����8����dual for
hire who does not possess a license, vided that ' '
P I'o t h e o w n e Y a c t s a s
. , , suPervisor.
, ;'�:n', „,. ._,: ,. ,
v, .,.. ;
DEFIMTION OF HOMEOWNER: ��
Person(s)who owns a patcel of land on wlrich he/she resides or in�ends to�d��on
which there is,or is intended W bey a one or two family dwelling, attached or detached
struchues accessory to such uae and/or fazm shucturee. A peisott who,constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowne�"shall submit to the Building Of�cial,on a form acceptable to the Building
Official, that hdshe be cesponsible for all such work perfom�ed under the Building
Permit.
The undersigned"homeowne�'assumes respo��bility for compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned"homeowne�'•cerdfies that he/she understands the City of Salem
Building Department minimum inspecqon p����and requirements and that he/she
will comply with said procedwe,y and i ements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING 1NSPECTOR u L
See other side for state code
�
'i
ox
HOMEOWNERS EX��TI
The Code statea that: "AnY Homeowner Performi�►g work for which a Building Pennit is
���atl be acempt from the pmvisions of tlris section(Section 109.1.1 —Liccnsing
� of Consroruction Supervisors);Pr°vided that a Homeowner engages a person(s) for hin w
do such work.and that such Homeowner shalt act as Supervisor.
Many Homeownera who use ttris exemption are unawaze that they are s.m,,,,i*+g tha
responsibilities of a Supervisor(see APPe°dix Q'RW�����ons for Licensin8
Construction Supervisors. Section 2.15). Thie lack of awareness�r�� �Yo�
problema,Pazticulazly when the Homeowner��°t�a��a licensed
Board cannot proceed a8ainet the unl��e�s�p nsible.
gopervisor. The Homeownec acting as supern�is ultimat�lY resP°
�,v�
To ensure that the Homeowner is fully aware of his/her responsibilides,many
communitiea require, as a part of the P.ermit Application,tbat the Homeownthis isasue is a
he/she understande t�►e resP°�ibilities of a Supervisor. On the last P S t such a I
form currenflY used by severat towns. You may care to amend and adoP
form/cectification for use in yonT eummu�tY•
E,�r`
R� Glfol yoos
�
I o
� CITY OF SALEM� MASSACHUSETTS
S' 4
� � PUBLIC PROPERTY DEPARTMENT
12O WASHINGTON STREET, 3RD FLOOR
��m6�� SALEM, MASSACHUSETTS 01970
STANLEV J. USOVIGZ� JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildins Department
Debris Disnosal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Pernut is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
D�J�'l.� -1�(��-�-{� (Location of Facility) IV ��� f�uC ��l�r/�
Signature of Applicant
/ �,S O 5,--�
Date
r
Massachusetts Department of Environmental Protection
� Bureau of Resource Protection - Wetlands
, city/iown
WPA Form 1- Requestfor Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important
When filling out 1. Applic
forms on the �f pn/ ���(� R j�(/��r'o c,�/l 4� �JMC�i S�n
computer, use �� `���
only the tab key Name /J E-Maii Address
to move your � /`—�^✓Cl��� � �
cufsof-do not Mailing Ad ress
use tne retum � ��C r/Y� � �— M/9— D/ 97 O
key. Cdy/Town State Zip Code
� _ 97�-- �7`f`f�S"l�3 S'a M-�
°6 Phone Number Fax Number(if applicaWe)
� 2. Representative (if any):
�
Firm
Contact Name E-Mail Address
. Mailing Address
City/Town State Zip Code
Phone Number Fax Number(if applicable)
B. Determinations
1. I request the make the following determination(s). Check any that apply:
Conservation Commission
❑ a. whether the area depicted on plan(s) and/or map(s) referenced below is an area subject to
jurisdiction of the Wetlands Protection Act.
❑ b. whether the boundaries of resource area(s) depicted on plan(s) and/or map(s) referenced
below are accurately delineated.
❑ c. whether the work depicted on plan(s) referenced below is subject to the Wetlands Protection Act.
❑ d. whether the area and/or work depicted on plan(s) referenced below is subject to the jurisdiction
of any municipal wetlands ordinance or bylaw of:
Name of Municipality
� e. whether the following scope of alternatives is adequate for work in the Rivertront Area as
d>e�picted o�n referenced plan(s). / /� 1
WL. Alrin � l'/�G�-'G� �t/ �J�t � �� 7k-a- ��r77o�-- Fi/! U�i✓/C�
��CG�s//i"�p�S D-�,�IQC� Wr '� nv Ma �%�t ���e/V �%T
Or Sr�f l✓L L✓ �/1 n✓l � /IkvC S7d4 � rl �i �trfi� a �uCl�
.� �� ,��e t.�aY �'� �I ;S�os� (.
woalortnt.tla•rev.W/74/06. Papa 7 oi 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands Ciry/Town
WPA Form 1- Request for Determination of Applicability
Massachusetts Wet�ands Protection Act M.G.L. c. 131, §40
C. Project Description
1. a. Project Location (use maps and plans to identify the location of the area subject to this request):
'7 � � ��� b�� K ��.. sq (e.�
Street Address CitylTown
(Y1�.0 _� 1 � l.o-�- 02�}tY
Assessor Map/Plat Number Parcel/Lot Number
b. Area Description (use additional paper, if necessary):
�S��a1� -��; (.� �o� r�;-f��.- ,`�� ��s�" ,-�r�f
��oit�q� . �
c. Plan and/or Map Reference(s):
TiUe Date
TiUe Date
Title Date
2. a. Work Description (use additional pap(e�r and/or provide plan(s) of work, if necessary):
��1��RTI^o✓1 a"�' c� � �D!�!i✓�2� Y'� -
l�Ot/� �� r t" , ✓lci � �i 1/��ll � � L', �
�i�nr�S� CR� �v17',rt/ Gidl� f�°C /'`�� ��-
� wnaiomn.aoo•r�.o�naoa.
Paga 2 014
Massachusetts Department of Environmental Protection
� Bureau of Resource Protection - Wetlands �;�,rtoW�
' WPA Form 1- Request for Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description (cont.)
b. Identify provisions of the Wetiands Protection Act or regulations which may exempt the appiicant
from having to file a Notice of Intent for all or part of the described work(use additional paper, if
, necessary).
I
3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Rivertront Area, indicate the one classification below that best describes the project.
�Single family house on a lot recorded on or before 8/1/96
❑ Single family house on a lot recorded after 8/1/96
❑ Expansion of an existing structure on a lot recorded after 8/1/96
❑ Project, other than a single family house or public project, where the applicant owned the lot
before 8!7l96
❑ New agriculture or aquaculture project
❑ Public project where funds were appropriated prior to 8!7/96
❑ Project on a lot shown on an approved, definitive subdivision plan where there is a recorded deed
restriction limiting total alteration of the Riverfront Area for the entire subdivision
❑ Residential subdivision; institutional, industrial, or commercial project
❑ Municipal project
❑ District, county, state, or federai government project
, ❑ Project required to evaluate off-site alternatives in more than one municipaliiy in an
Environmental Impact Report under MEPA or in an alternatives analysis pursuant to an
application for a 404 permit from the U.S. Army Corps of Engineers or 401 Water Quality
Certification from the Department of Environmental Protection.
b. Provide evidence (e.g., record of date subdivision lot was recorded) supporting the classification
above (use additional paper and/or attach appropriate documents, if necessary.)
wpaforml.tlac•rev.07AM04. Paga 3 0l0
Massachusetts Department of Environmental Protection
� Bureau of Resource Protection - Wetlands c;,yRo,�,,,
' WPA Form 1- Request for Determination of Appiicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Signatures and Submittal Requirements
I hereby certify under the penalties of perjury that the foregoing Request for Determination of Applicability
and accompanying plans, documents, and supporting data are true and complete to the best of my
knowledge.
I further certify that the property owner, if different from the applicant, and the appropriate DEP Regional
Office (see Attachment) were sent a compiete copy of this Request(including all appropriate
documentation) simultaneously with the submittal of this Request to the Conservation Commission.
' sai of the Re uest for
Failure by the applicant to send copies in a timely manner may result in dismis q
Determination of Applicability.
' Name and address of the properry owner:
��� ���/l�
Name
� ���✓�.��� � f�d
Mailing Addres
(es�-t , r1?A
��ty�o�, o r� 7 �
� State Zip Code
Signatures:
I also understand that notification of this Request will be placed in a local newspaper at my expense
in accordance with Se,tion 10.05(3)(b)(1) of the Wetlands Protection Act regulations.
/l / aJ
Signature App ican Date
Signature of Representative('rf any) Date
Page 4 0l<
wpe�ortni.tloc•rev.07/7G/Od.
1� '
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OEED:RECEBK. 22a�� P�' 2q�
PLAN: QR�(GAGC THISPLOTPLAN WASNOTMADEfROM
T0: (`�E (�I�OV E S M AN INSTRUMENT SURVEY AND IS FOR
THE PURPOSES OF THE BANK ONLY.
1 CERTIfY THAT THE BUILDING�S)SHOWN HEREON UNDER NO CIRCUMSTANCES ARE OFFSE7
ARE LOCATED ON THE GROUND AS SHOWN AND THAT THEY - T�gE USED FOR ESTABLISHMEN70F
CONFORM TO THE HORIZONTAL DIMENSIO�Af AEE�ATIONS FENCES,WALLS,NEDGES,ETC.
OF THE ZONING BYLAWS OF THE L�ty hqORTGAGE INSPECTION PLAN
pT THE TIME OF CONSTRUCTION OR ARE PROTEC7ED UNDER
GENERAL IAM�S CHAPTER 40A SECTION 7• ���ArEp AT
1 ALSO CERTIPY TFiAT THE DWELLING SNOWN IS NOT � NOF inq �
\��,t ss r 7 RIVERBANK ROAD
IOCATED WITNIN A FLOOD HAZARD ZONE AS �� SALEM
DELINEATED ON THE MAP OF COMMUNRY S 2S o I o'L
SPLEM MA.EFFECTNE 8•S'85 0� GAIL �s�, PREPAREDFO�� � Mo�Ly BRo'
F '- ALE� gRo
BY THE FEDERAL EMERGENCY MANAGEMENT A6ENCY. o sMitN �^
No.35043 Q, Of
� ^C-��� �o ,�' SCALE7"= 20 AvSUS? 12 , 2
U ?
( ,� � ��'`fs F���R �� NORTH SHORE SURVEY CORP.
/ V s'nront i Ft:�`' 47 LINDEN STREE7, - SALE#,2341 F
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p�E��� I �REG.PROFESSIONAL LAND SURVEYOR
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