15 SALTONSTALL PKWY - BUILDING INSPECTION CITY OF 3XX1.t!,iV1L --
PUBLIC PROPERTY
DEPARTIMEINT
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I ✓h f�j i/� , 130 w&**NGuw bnmrmr•"'�.MASS.�O1cSL1'M 01970
�l 1 I'm 976.74S-959S*FAX-976.740.9N6
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 Hlstorkc dMict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: o Pio �"L l
ale w., >✓1A olq'7 b
Telephone: �1-7 510 2,-A?�
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Pc Existing �Pf�.��s�•
Renovation � Number of Stories Renovated
Change in Use O New
Demolition N q Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bdd Description of Proposed Work: -('p
�
Sln�h �S o`vt� re - rower t �r1� �ycr- �•� t �mbpet-1��e
Arch � �ec�vlq� cGev,4\A-
udder, p i e1F. t bra�l�e�, � ► KS b � rJec�
S�Se ill �s ill a5 4�rQS or Pr ey ltovl.
n
Mail Permit to �h AJe h� „r 4 D�154
What is the current use of the Building?
jV
Material of Building? 2 �j =5�d"elliri , how many units?
Will the Building Conform to Law? <) Asbestos? /l/t-
Architect's Name
Address and Phone
Mechanic's Name Q�` , `L --
Address and Phone 3 F� T '� r en I
Construction Supervisors License#:e 6 9�y HIC Registration#%,;K-xr7N
Estimated Cost of Project S 9 g a A o Permit Fee Calculation
Permit Fee i 16 r Estimated Cost X$7/$1000 Residential
---- - — -- - - -.--- Est►mated-CostX ill/f1000 Commercial
An Additional $5.00 Is added as an
Administrative charge.
�G _ %0
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 /� <- - wi
Date ^/ ,� �n 7
e
Ja
x °off er a o
9 b
F •� 92
a
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Worken'Compensadon Imuraaee Afddavk: BwMawContru
Anotlt ast Informadou plum Print UAW
Name l \�,co 0 r J,till
Address:— �� /�/„D AI-C -
Ciry/StatelZip:- - ,�,o�#r�_ . l`7Q_ �_►�5_ Phone�Ik _7d1-;�,�iS-�GS� -- -
A," an empbyer7 Cheek the appropriate bm
1.Lfd 1 am a employee with 4. Q I am a pineal comsat or Type and I Ty �Proled(n9csirsk
employees(!WI and/or paeF =).* have hired do sub4otmecanns 3 ❑Now cmeroedos
2.01 m a solo priviseor or pama& listed an the attached cheat.t 7. ❑RemodeHag
ship and have no employees Thal>va000tractam have A. 0 DemoBtim
working for ins is any,capacity. walrere'0001146 iOOnenea.
[No wader'camp inaueams 3. 0 We sa a caporatim and is 9. 13 widing addtdcs
requimd.) officer have exenised their 10.0 Eleeh{cal repairs or add3[ans
3.01 am a homeowner doing ail work right of exmaption per MOL 11.0 p1uismax repars or+dmone
wault DW workers'comp. a. 132,41(4).and we have no 12
imatrance required]f employees[Nn wart=, repaills
�p isatnanes � 13.[�hRaw
r'Any WANN dia dud s n not.tr ea ore saur e+u.re.y r�r�0e
utaeeswae TAW ei.ie ttlr elaaarlt tattq iaarnrsra.
ral
rCarrueaa err eyed ri4 ter ed raeetr/r dBN W rA�rt d�adr ri er tie aurldr evra�e yes rotrk e w al�va 6iYaliyraaL
dewier lie res der wieoatrrrsrw rd dtrir worbea'eaarf.Peffer idemdan,
f . fAert b wentas•nwpwaakoa kUMUN f r AW employees Rebw b W peflej mr/Job sift
Insurance Company Nams: y, S
Policy 0 Or Self-ins.Lic /� Expiradon Datr_ Cl�/� e) 7
Job Site Address K �c✓ n fi /l Jt� y�S 76—>
Attach a cW of chi workera'compenatba pe ft declaration pas(showing the poBey Number sad Kpintlsa date
Failure to secure coverage AS requited under Section 25A of MOL a. 152 can lad to the imposition ofcrimisal PROM"au
fine up to S1,500.00 and/or one-year imprisonment,as well a civil powd"in the lam of a STOP WORK ORDER and a Bon
of up to 5230.00 a day against the violator. Be s �y of Ibis cement may be law arded to the Of]!p of
Investigations of tbs DIA tar m nnna coven v
adkadm I do karrbp cwW&under Ibeoelas and eJ r/ diet as la/avaredowOrttlded b Over and cerrres ne
3R
O,Q?ewass talp Do act Wrist to nib oreiq,re be etayleW by c4 ear Iowa o,Qle/d
City or Toww. PereaftIl icesse M
fuzing Authority(circle 0").
1. Board of llealtl L Building Department 3.Cleylrown Clark 4,l:leetrical Inspector 3.Plumbing Inspector
k Other
Contact Person; Phone Yr
information ana lns[rm;%aw"o fa�►eisemPby"L
yasacbuseas General Law$chapter ink a..XVM Pat=&00iss the daaeview;of Y °f tea'
to this state.an eseple
express ter oral a.aittes
association,eosPond°s or other leisl entity.0e any two a moae
ea detioed""aa iodivWu4 pasmsrahiP. ves of a deceased emPlGW-a the
An*JVWftWp of the foewi t edYsfed m"join''0' �lepl�mat7l��P�Y+ai �
reeaiwr of ttrim,"of m ind►vidua�.pasa�?' tubs tfto a therai4 a the oexttp"s of the
waft
owner OfWAN> t sst"sera thez boa or tspait once ca atcl dv h°°as
dwdlint WM s shall oat 0 de teses of sacb empioymeet be deamod 0e be tee®pioysr.'
or on the ga terthe bmlffiot aPPeQO"'nt _
WM chap w 132.1�6)also snag that"ems s h u�Is tw eo��or
o<a tlee.ss K pereslt r• wa*a mbdivldam
�aSit WM b"net ptted.red evWee"e[eempta� ift shaII
aPP& ht(it:d-Ptw 152.125QI)estates Neuha the dence of COMMM's with 68 inanoa
enter into My' ."dew the porfoemaou of P't m°ihe caoaaednt a .W r
requirementsotthis h:w been presmtad
Avvasab checkiat the boxes that apply a Your situation and,if
Plea"fill cut the wodxen'c ms affidavit '�one (.)along with their eaafiate(a)of
address(es)and Limi Liability aOMP`so •°m(.«ix aesd0° L with oo__ ° th.n the
mmmuc iaauranp IfmDep at of ladoat"
member+or is ed Be advised that thin of ldavil may b$wbmiaed to the affida m
employaea. ..S, Abe be seas is arp and d:n the aAWav1L Ths affidavit should
Accidents far of insunaee tan the pit at licaose is being rcquestM4 not&a Department of
be returned to the city or toarn due the appiladen the yam,or if you are c"* co m obtain s old enter
Industrial A, Should ym have any qw damregarding listed below. Sel�inated companies sb°sid esur their
COULpMN*n poft.pum au the Dguun"lid.
self-inst M e ilrada stmsb—c s the
svimlde
CW or TOM txtd.b at the bottem
� The Deportment has provided a spacePlea"be tun that the affidavitle is complete and Printed 0W has to contact Yes►repardiug the aPP�
of the affidavit for You to fill out in&a event the Offlee of invesused as
Pies"be sum a fill is the Swnwlicm"member which will lw used es are only s number. a add.">i>�
that must submit multiple Pe+m�°sN applications in any grvm Yea.need shoo submit one affidavit indieadng ammt
policy information(it nee. =rY)and undo Job Site Addeme"the applicant should write"all may
be p o to
the or
that h"been offioielly stamped or marited by to city er twv.may be provided te the
tow. 'A copy of the affidavit u m file for Huse permits or liem"s. A now af;,de vu must be tilled out each
applicant0 proof that a valid affidavit a U..at permitnot related to any bUdn"s or commeK"d v"a"
year.Where a home owner a eid3 m is obtaining is NOT raluired to�mVIOOs.this afpdavit
(Lt. a dog Hoene Of P°ssk to here lesves eM)aid person
The Oi�fice alfaveatigauona woetid lily to thank yes.is advance for your eoopendon and should you have any qu9stion4
Please do no hesitate to Situ us a alL
The Departmews addresw telephone and titer aumbec
ju Comt:tonateam of MLawbuca
Depermuat of Ii &nMW A=d=fs
0f%*d VvudgM zJl
600 Wa llinOW Sftd
How%MA 02111
TeL 0 617-727-4900 cd 406 of 1-977'MASS"8
Fur,6 617-727-7749
Uvised 5-26-OS www.mt wgov/dies
CT1Y OF SALEm
' PUBLIC PROPERTY
DEPAXrMENT
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tide welt abail b•dtaooaed otbt a popes►geeaaei vaa0e dtapad dtegtgt>.dadaed by lfRlf.s
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(STRIP ROO OF aaezrw.-.LAVERS OF A5PHAIJ SKINLILES.COVER EXTERIOR WALLS AND FOUA�
fWl1•H TARP To tl,,,ELP PREVENT DAMAGE.ADDTIONAL LAYL HS WILL HE EXTRA,SEE DCI.tTW
�aJ OVER DE will UNDERLAYMENT PAPER.
NSTA .IG "VI'l SHIELD Al LFACING UL-x VALLEYS AND ALL ROOF P NCTRATION
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Ilya(( OVER ALL ERIMETER6 W'O"0 INCH ALUMINUM
9 9 FOR ADDEDATT'• H"ITILK-ON.
RR IWGR ff1P1'EF
INSTALL RI E VENT CR CL—. HOOF
N3TALI - IT VENTS WHERE NECESSARY PHR MSTRUCT'ONS BELOW.
COVER V,DI PIPES Vil NEW PUBOER FLF.9HIN3 BOOTS,
" NEEDED-
COUNTER SH CHIMNEY(b)WITH AWMINUM FLASHING AN NEED�DHIMNEYIF]),GUT NEW RE 'I� T,
RELEAD C Me*. CUT ALL EXI6TING TAR ANO LEAD FROM. �_
CEMENT N W LEAD IN PLACE WITH MORTAR. IF NEEDED FOR A WATERTIGHT JOB'AODO ABOVE PRICE.
CStLLC O MNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD .—
Bill FEPTIVE ROOF O9011 W NE AT TRA T S DI ETIOGc SEE
Gail A F SURFACE WITH dW- I•
5TOr7M N ALL SHINGLE9 WHEN APPLK:ASLE(SE F .INBTRUGTI Me).
FAMINSTALL 5 LIGHTB PAOVIDEO OY CUSTOMER, FRAMEO RO�FEDCuyrpMEA YY'�Q01h 'E- ?f rOwsif.WJ
WITH FL ING KIT(8)PROVIDED,ADD .
F MORE YER$ARE FOUND THAN iND10ATED ASOVr.,AN ADDITIONAL CHAROE OF C WILL ALL
AD D.
CLEAN AL JOB agATED DEBRIS FROM OUTSIQE YVDRK AREA, OBTAIN ALL.PERMITS OA��A",.-i
NE ES INSL'RANClIB�S REQUIRED By �L CS, DRZgT.Cw 0�W 9,USED ��CI T617
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REMOVE. ISTING GUTTERS I9:;HL"TION,REPLACE WITH NEW
REPLACE TTED FASCIAWNERE NEC:L'SSARY*�OUVR�oC�T pITNERWISE DIFFGTED. F:FIST 7,•FHE-F.
PRIMED D,COV5R ii ALUMINUM CWL 6 u
THEN AD PER FOOY TO A3CVC PRICE
I ,NSTALL t W BEAMLE68 OWi ALUMINUM GUTTERS USING THE PO61TIVE LQGKING SAR HANGER sY)3T- 2r
INS?ALL W'ALUMINUM 0OWN8POUT9 AND LEADERS 7JP IN ALL GONNPOTIONS.
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HOME IMPROVEY NT CON F yt,Y'OR.
Registrat�4n� 151 r. , ,• war:
611 E
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JOSEPH S SAV I. I �` "
,�fGPHSAVINI�.
33SHIPAVE �>-� a�J:
� MEDFORD MA0215�
I AJminldtralor
;,'+p,- ":.i �e >°oo��tatoruaea/.!� o�./uamaaEudelld
BOARD OF BUILDING REGULATIONS
Licenser: CONSTRUCTION SUPERVISOR
Numl;r 0 036954
' BI -1955
".{.. 7 Tr. no: 15595
R itE�
• JOSEPH S SAVI Ili
I'! 84 RAVINE RD G'-
14 ? MEDFORD, MA 02
Commluloner
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/1\Iel��� Lfi �R •'. '. FNu! L71Lr1TE(MMSOD'.Y Y)
I I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PRESCOTT s .SCV INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
963 EASTERN AVE ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
YALDEN MA 02148 COMPANY
775TT A
INSURED COMPANY
JCSEPH S SAVINI INC B I
B4 RAVINE ROAD COMPANY
MEDFORD MA. 02155 C
COMPANY
D
COVERAGES. ..
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIGC
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH I'I ,£
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T'HE TER::I'_
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LEE DATE(MMOD�YY) DATE(MMDO�YY)
GENERAL LIABILITY GENERAL AGGREGATE i
COMMERCIAL GENERAL LIABILITY PRODUCTS COMP/OP AGO i
CLAIMS MADE=OCCUR PERSONALS ADV INJURY
OWNER S d CONTRACTOR'S PROT EACH OCCUR HENCE
ARE DAMAGE(Any ona ei el i
MED.EXPENSE(Any ona person) i
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO LIMB
AL L OW NED AU TOS BODILY INJURY
SCHEDULED AUTOS (Per Parson) i
WEED AUTOS BODILY INJURY
NON OWNED AUTOS (Per Acddenl)
PROPERTY DAMAGE
GARAGE UABIUTY AUTOONLY-EAACCIOEN? i
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT
AGGREGATE i
EXCESS UABIUTY - EACH OCCURRENCE 3
UMBRELLA FORM AGGREGATE i
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND STATUTOPY UMRS N/A
A EMPLOYER'S UABILm (UB-8067A00-0-06) 09-12-06 09-12-07 -----
' EACH ACCIDENT
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT
PART NERSeE XECUT IVE
OFF�CEPS ARE EXCL DISEASE-EACH EMPLOYEE 3
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSVEHICLES'RESTRICTIONSISPECIAL ITEMS
"HIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVE3_,S_
CERTIFICATE HOLDER ., .'
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE In.
EXPIRATION DATE THEREOF, THE ISSUING COMPANY VALL ENDEAVOR TO MA.:
10 DAYS WFUTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TC T.H_
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION CA
LIABILITY OF ANY KING UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25-3(3/93) 993