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20 SAVOY RD - BUILDING INSPECTION C a _ ddlllST-9E fiL-EG-AND''APPROVED BY T44E W5PIX3*OR ,PIWR TO A PERMIT BEING GRANTED / p / CITY OF SALEM No. CO 97 0(7 :- mot `` A� �\ Date 2 Z. Is Property Located in Location of the Historic District? Yes_No_ Building 7 p Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof Reroof, nsta I ' ' g? onstruct Dec Shed, Pool, Repair/Replace, Other: acpOt-na+.l c 2-0k\mPA-T1ow1 PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name SIA-AwE --V-) " y(Lei h2l�" N Address & Phone 20 5I:W0q Qh I ) Architect's Name t XIM&Z Address & Phone 152- .uAcAky36*ot.1 (-7911 ) 631 7 4HO i Mechanics Name ) 3 � �j Address & Phone ( ) /$ What is the purpose of building? 9Vi�% n curt A i Material of building? ,x If a dwelling, for how many families? Will building conform to law?�S _Asbestos? IU O Estimated cost 3©k6oD. City License # N A State License a rS 05�,62-15" Rome Improvement i Lic. 1 +L`- C` Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE R -2� SImc.01J FatLe-4 DETA[o ADn dN A t,�11 cD W\7r \L\--r a QN Q)57Mtm1 fz MAIL PERMIT TO: c;L10. lilU$-V1flU� NVE L-q N M N114 nIGOy No.� APPLICATION FOR PERMIT TO /y/n LOCATION l/ aw �o PERMIT GRANTED AP ROVFD ' °�,rne o INSPECTOR OF BUILDINGS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dta Workers'Compensation Insurance Affidavit: Builders/Contractors/Eledridans/Plumbers Annlicant Information Please Print Leeibly Name (aasiness,4Orpmzationftdivduo: ti;F—d1J C'bNS`teu -hnrJ ,y�11�1 Address: S!{4, W ES ta(h.) Iky F City/State/Zip: Lq W t3 , A" !p Pcj 9t. Phone Are you an employer?Check thr appropriate bore' I. I am aemployer with 4`. I am a Type Protect(required): general contraaor and I 6. ❑New construction employees(filll and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working,for me in any,capacity, workers'comp. insmanee. 9. Btuldmg addition [No workers'comp,insurance 5• ❑ We area corporation add its' regnved}_ officers have execrseti their 10.❑ Electrical repairs or additions 3.❑ I am a bomeowner.doing all work right of ex "emptitn per ItitGT." 11.0 Plumbing repairs or addition myself. [No workets',comp:. c. 152,§1(4y,andwehaveno 12.❑_Roof repairs insurance required;]t. employees. (No woiketil' 13.0 Odrer comp.insurance regnaed:j 'Any applicant that checks lox MI swat also fill out*a section below showing*A*%wker'Conlon polity mfometay' t Homeowners who submit this affidavit indicating they an doing all work and then him'oalside eons must submit a new aidevit iodieazing such tCoatr waM that check this lox'tmut ettwbed In additional sbeet showing the oame.of the sub ooetrec[ms and then worker'co np;policy information. I am ad employer that Is providing workers'contpemadon huurmice for my enipldyees Below tr the polity and fob sh'e informedon. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: (o 6 Job Site Address: J—a S V A Y b City/Stateizip:S ALemj Mrs- Attach a copy of the workers'Compton don policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a Copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cerdfy under the pabms and penaltict ofperjury that the hrfwmadon provided above h trot and correct Simature: Yo r ti y1 Date: 117 2,1 Oro Phone#: —i rh\ Mal) S9 S 7 OJJicla/use enIA Do not write in Als area,to be completed by eUy or town o f'kid City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chaPTa 152 requires all employets.to provide workers.' compensation for their employee. Pursuant to this statute, an employee is defined as"...every.person in the service Of another under any contract of hire, express or implied,oral or written." An employe is defined as"an i�ividiial,Partnership,��tiOny corporation or other legal entity,or any two or more of the foregoing engaged to a joint enterprise,a d including the legal of a deceased employer,Ho v the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having of more than three aparWents and who resides therein,or the occupant of ilie-" dwelling least of another who'employs persons to do maintenance,construction or repair work on such dwelling house thereto shall not because of such employment be deemed to be an employs." or on the grounds or building apptutenant MGL chapter 15Z §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or pew 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,MGL chapter 15Z§25C(7)states"Neither the commonwealth or any of its political subdivisions shall of public work until acceptable evidence of compliance with the insurance cute into any contract for the performance requirements of this chapter have been presented to the contracting authority." Applicants . situation and,if workers'compensation affidavit completely,by checking the boxes that apply to your s of Please fill out the their certificate(s)) necessary,supply sub-contractut(s)name(s),address(es)and Phone number(s)along w< insurance: Limited Liability Companies(LLC)or Limited Liabihty.Partaerships(LLP)with rw 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 The affidavit should Accidents for confirmation of insurance coverage Also be sore to sign and date the atfida not the Department of be returned to the city or town that the application for the permit license w or if Y being equi ed to obtain a workers' Industrial�Accidettis Should you have airy questions regarding compensation policy;please can the Department at the number listed below. Self-insured companies should enwr.their self-insurance license number on the to lip City or Town Officials Please be sure tbat 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 er. In additiOU,an applicant Please be sure to fin is the permiNicense number which will beused a reference need only submit one affidavit indicating current that must submit multiple permit4icense applications in any given y policy information(if necessary).?nd,under"Job Site Address"the applicant sbould write"all locations is ed to the or town)."A copy,of the affidavit that has been officially stamped or marked by the city or town may be provid applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each taining a license or permit not related.to any business or commercial venture year.Where a home owner or citizen is ob (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do of hesitate to give us a call, The Department's address,telephone and fax numbs. The Commonwealth of Massachusetts Department of lndushial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617 72 7-7749 Revised 5-26-05 www.mass.gov/dia x ' CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOYICZ, JR. TELEPHONE: 978.745-9595 EXT. 380 MAYOR FAIL: 978-740.9846 Salem Building Deuartment Debris Disposal Farm In accordance with the provisions of MGL c40 S 54, a condition of your Building Pernrit 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: �u Mo ?-tea ty)��,lA U La --�— (Location of Facili Signature of Applicant _2-) Date Zt- _ - ---- t ? a ------ ----------- ----- —————————- ------- -- — ---------- ---------- v gA I m apta3E3t/4 11111ge a { s 1 IS !? ;o3il a iP4t1j?.l1,I P?lIi;j1.,1P 16f?1t.1aPl Pd Il.P'li1,l1asJ,Il tj.tl'i 1l'1Pi.r�n 1r)l►P;t �'t I�?t,1i,1jUj•!1•1!;i I!P?jI l4ifl?d1r('Pli'!i!It l.lI!I{ji'?l P! t(IP1 rlp yjrr"U tt'li4 r•y(? ; llJfill fit (?ij :I I• o J 7• ` I I t ,?"i J j' I 1 rl ?' PI z WORM 14111 (ICI IfP 1�1 j iil�ij �jiff Ml ([� 9 ;i� lI ji�' r !1! fill t'{ jil loll fill, tall fili fil111H Ill I n 1t( , P Ij O� I F O 1 a N •� I r O� '• YaiZM it 118 1 g iRF�'- 3y Cy t ;IWO it all 1 1141 �m it sa ir Cover SheetlBl Design Development s i ��itzs �� CS. 1 andlitect Waiter Jacob ` t52 WasMn"Sheet T Marblehead,MA !� 781.831.744O i! X �1i a mum m. a dpe C OAFd 20o071 i it 11 PROM FROM STP@r R4cm BSTamEOF BnW PMOIp FROM PFM F/$!G PEAR(SOUfM ADB OF MOIbE PIg1p RIOM eIAEEf FA@1G EASE 51[E OF MOI.eE PHOTO FROM DRIVEWAY FAGNG OARAOE I mw Z4 PHOTO FROM MEET FACMa MAST AOEOF MDuc-E �p9�UTA /l �•=f•�—o• �— , ea eaw ebaeee U . � y�e�M.nl esme Fber Pbn �ee.anMmnaw Mm R l i a m --------------- I � C3 o I i i Air E I i _ EMU ' I ssA mr p V 0� i �;J C o6 � FIMrIBrwppb aWBmb, ��tl blPW_______ Cm t mC O Franklin Residence S - 20 Sawy Road,Salem MA r i t jNji ri L lla j/ o 1 a 'rl x'o ' eo d� 0 'A m r —J I I Id i I r� li !�a lii Ig! I I I I a II d� d� �1 0 41 m � O P N ;mysh m m m m Pmposed Floor Plana + + + + ++ y Design Development i i&ta s Al arebkect VJarMJawb N 182 WasNrvWn Street , Marblehead,MA 781'.831.74/0 m ux.um eb MMN C�wn d, tl�M ' pebtl 2�1 I ® uw n a m� I I S I I S n ,m ® a �— I I X --------------- Mb I I 4 lydt R� I j m E �n � m I4g� Franklin Residence ao 20 Savoy Road,Salem MA architect Waller Jacob OS 152 Washington Sheet 9gp.1 Marblehead,MA V�p23 781.031.8T.831.7100 _ QOR . =140 Mb YNob] Eg CIM i tl�yY1 Pchd 30.0W1 m miv�N 0 e 9a We i OF t EIlVYt'on 08 $C tP Franklin Residence ao 20 Sawy Road,Salem MA architect Waken Ja b N 152 Washington Street Marblehead,MA 78l-e31.74/0 QQ 01�os i Y Y�C�iV�D,tOli 0gCON q ae.um �f T` b NNdN T1 � www m er.e M vowled 2m3mt ' vwrw wa a woos mnm, i a9�.ffiY o®"w x oe ® e�q wurrasz 0 v�v q C �ww og.aw,o.wag, r pvp--F� WE y t �a c Franklin Residence reo - 20 Savoy Road,Salem MA i! t _ r RE: 20 Savoy Road, Salem Homeowners: Kim and Shane Franklin We are planning to appear before the Planning Board of Salem, Ma April 21, 2005 to review our revised-plans to expand our home. The new plan will allow us to demolish the existing 3-season porch and expand out our kitchen and build a deck. We will not be requesting to build above the kitchen to include an additional second floor bedroom to minimize the impact to and the potential views of our abutting neighbor(s). By signing below you are acknowledging that you have been given the opportunity to review our proposed plans and agree to the revision. a Print Name Signature Address r ( 7 l gh ,�Lc;. )�L eAC Print Name 7&ig ure Address Print Name Signature Address Print Name Signature Address r �[ 3:^4 ! ( ri(G`ti i tit ., (`V / �,il'✓J y �, �. Print Name Signature j Address Print Name Stgn)aturdJ Address Print Name ignature Address