96 SWAMPSCOTT RD - BUILDING INSPECTION (8) ��S�rT$EfIL. _ - ApmovED BY T44E
1AI$ FX3 DB ,PWB II?A PERMIT Br;jNQ GRANTED
CITY OF SALEM
Date
No.
\'�hmnscR'
Location ofar�
is Property Located in Building 1
the Historic District? Yes_ No
is Property Located in Yeses No
the Conservation Area?
BUILDING PERMIT APPLICATION FOR:
Permit to: Reroof, Install Siding, Construct Deck, Shed, Pool,
(Circle whichever apply) Roof, �u
(CI Other:
Repair/Replace, nth
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:
Owners Name r_.
I-�-t1Z�— / J4cq�e Li�x� Cow �i-ec
Gl7 �l�l .537
y�r ( 7 —
Address & Phone
U
S 1PAAArN �e5 r ✓, Kum
Architect's Name pace
7a -�i o G
( ��l 1 r � —
Address & Phone N&R����`9 /i1 `�
Javh
Mechanics Name
J�Ay,25 1 �� /
Address & Phone e
1s5� ti AJI
_ cko'be OF- FrzoZCN �oo�ies
What is the purpose of building? N
C 51ee— If a dwelling,for how many families?
Material of building? '
Aspestos7 N y
will building conform to law? N N to License # 1 G
G� A
Estimated costl r��y city Licensea<
410,616 Rome improvement Y
iL�Z'a n ig ature of A 'plicant
SI NED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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c c Ut 64e;' �vo i eS
MAIL PERMIT T0:
I
No.
APPLICATION FOR
PERMIT TO
LOCATION
9G u5wAntwsco.i-------------------------
PERMIT GRANTED
APP OVFD
G
ECTOR OF UILDINGS
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Bostoeiy MA 02111
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ADDdewd hformattoa Pkaae Prid L Mft
Name \,J "D CC NS�2ve-?4 u:N C6
Addresf: `/3 ik)e Ks U l 1(6fj { 2-P-
City/State7*. e4- ;` • Phaae o.- �03 e&-7 Z!
Are you an tin ?Cie*th6 olate boss' Type of
1.❑ I am a empkw wins I am a Pied���-
(denial bmsotadsr sod I oomuactiaa
employees(W sn&ccjwrFthne}• haw kin d tksaab 4simesom 4 ❑New
2 dam a axle poprielor ar psstaea lisad on ma sales d stet t 7. Q�odetisj
A*and have noemplayea Thesesab4mmadoohave >L ❑DemoMm
woditfiW oiaaWtcapmft.. W"l '.WMP. . ., 9. Q adOm
(No workas'GOOD inauasoe . 5. ❑ we ate 4 corp-atioa
oBCcasliiyeese�Ledg� 10.0 Flectrieaitepaut or additions
3.❑ 1amabomeownw.doisg all wmk rightof �pefhlCZ' 11.0Pkembiogrwitsor"litions
w Myself[No rkw comp G. 152,f l( aoil. ye'iio 1lb RoofCOM npaur
iaaaraoa f;
ME]Omer
f.►ny dWdwbtmrlUMsa..fillyR4t�sbdow�ovtymdrw t ia�9 oa
coy.abmq"dB&vk"Deft&ro+6*6.Awatada.tTwo.e ooatliwa.alodmbma•.i. .�vitt GMwk
rCnamca s dotdakthbai me aftrbd a O&Nd nit d"dnviq owl t[e. ..IarYv.odbra'cmP t+ 7 i *++odaa
r Gar grawpJorwthat b pro►�na werJfsra'eoaipsaaaflerr baarsd'?fir a4ea�AeesE dafoN b rAapalky aarJJoj Gills
►XfwwM
hours=Companyxama 5L Ce Co.
Policy 0 or SGIf ins.Lies S rn AG %! 7 7-S 7
Fapita8on Dace: 1,766 7
rob Sire Ad&= mil'� .SC /,A0 SCv City/3ta0rl* S4 /e AL,7�
Attack a copy of the workeW compensation polky deelWMW pate(skowMg tie Polley asmher asd espiratloa date}
Fatlme to secoM euvenge a.requW ands Section 25A ofMGL a 152 Ca lead b me kVoddon ofaimmaipenalties of
tine up b$"500.00 asd/Gr ono'year bWrisoamem,U well s Givd peailiid in me form of a STOP WORK ORDER and a Sae
of up b$250.00 a dry against me violabr. Be advised mats copy of this ara0ement maybe forwarded to dw Office of
Inveadptions of ma DIA for insoama coverage vai9gtioa,
r a borby rAra parcan ofP"*7 d w AN brfwwa kx prov1*d abase is aw art earset
G
O,oidd rw mal Di not wdw Im ft ana,fa k cowpkad ti ells!ar&wn,,JWd
City or Towns Pan jena 0
Inning Authority(eirde one):
1.Board of Health L Building Department 3.Clty/rows Clerk 1.EkcbUd Inspector S.Plumbing Inspector
6.Other
Comact Ferson. Phone#.
Information and Instructions
GaaatLarora ls2raguueanemalaaratbp'°`ri ywa W o
laym
iots qt , f "
iblmtat to dais StMIN is define°""-.evayya is>be ttav
--or imP>ied• wtrt0ea'
atio&"empo�tir aba!egad ca*9 at aY two or t»oae
isdividaal.paw �le�dties Qf a detxarad etttpwYC1;ar the
of the a i•i jotet��; ac oat lepl aotY.emP�'Y�t�PtoYb+' q�
o�a �mm dm*m s��and wm raides taaela.er aa�"v1ftS Loaw
dweaiot ioaae of mtther woo rmpwys paw b do maitttenaee.eomhac�a a repair wozk
dr ae the om;G O or bttt7dutt taaeb sass aotbecan of na emp%ymentbe deemed b be an cRUPloya"
Mt;.Cbq"192.12SC(6)aha It"duct"oaf Atria ar weal s8my did wfthMM tie hasten or
reo wal of a lla<a'a pew to antes
bashm or to cmdrtet batldlaP la the eomaaw�for aq
AffneSAwio has net produced aeeeptsbis"Meaea deemP"M w8h tM Israraaee eovaratr regtlred'
of conVam
AddifionallY.M($M dnpeu 132;pSM stm"Weida fie aom®oawesidt'um trey of ilt political shaII
utter ittlo airy et fo;tee pafpa",ofp 6dc west and amble evtdace cew�the imuraoce _-
,ritemasoftbirdtaPterbsvebaaprambdbAppResaft tbeaantradioi. "
tbebo=taat apply ftYaar si Uden sad,of
Phue tlq otu tee wodtas'compmsadaa 'c ��'b9 =xbe*)aloni�their ca idcoKs)of
naoerttiY:s 4ptY s)numv( addtetu( )tn4 P> otha tea ma
faswaee• � Oompa�(�or Limbo LiabtlgY P> (�-�wi8t m employees
members a p an not rogait'ed 10 tarry 'Mnpenrad=a>asoranee• If a ILC or LLP don bavo
CMPIWYOM a policy h re4�ea. Be advised tau"affidavit msy be submitted b the Deparetteot of wdnstrial
Alw b*jM to dP ad date the of MdavL Tee sffidsvit should
Aecideab ix�mW=of i0/maee oovetate a lieenee is be%g xquesN •nd tee Ducat of
be tebraed b the city or Mato�a application fir tie panut t0��a te.
]masaiai paideds. Mo M yea bttve say goad in rem tie law lo if yea ate [mA, C ti sionld eats tidy
pltaaa e3R the Deptetmat at tea M)lsged m SeU imurad oonopaie
� '.. appygq!IbL
7dFlnwtaee liceate>nmbt;�� - ..
CRY or TWO Offidals
a less sad pt�1�1y- 1U Depa�paeat has ptovtded a spas at the botbm
pleue be sure that the elude o Damp
ttom bas b wntact you regatdi0t tee aPP�
of tee affidavit fat Y�b out in tee event, the Office will a use Ia addition,an applicant
please be sere b fin in tie p 0°e n &jd which will iv used ar n re only submit
mbar.
tbst mat submit multiple P
licadam in any puce Y,ar nod only submit one affidavit indicating atrrea
,,ft fnSermn(if nccasuy').and radar"Job$i1a Addteas"tie applicant sltoaM ivrils bcadons d b
town}"A doPY otthe sfsdavit tint an bw offid�r tl PCM(l< r*4O" Ayw of w"mutbe fried out each
applicant s ptoo(tws a v9M affidavit is an Ace far fitme pemoa at aonmrsclat veabre
ear.Where a Dome owns or dtiam is obtamfot a!lame a permit not rdawd,b nay businessy a burn leaves etc.)said Mm is NOT regai r d 10 Dump»this affidavit
(ice a dot llama a pesmR
wouM WM toMA you in advance for your cooperation and sboald you bave any questions.
The Of�fioe of Inva igatiom m a ea9+
please do>nt aaitale ItHe
Tee Dcpartmeat's addMA wnpaone and fa n0mber
The Commonwealth of Massachusetts
Department of Industrial Accident
twee of Invesdgedws
600 Wasbmglon street
Boston,MA 02111
Tel. #617-7274900 eat 406 of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass-govidia
CONSTRUCTION CONTROL AFFIDAVIT
ProjectNuinber: t5?`P'DG -ZDOfo•od" Date: }ZGUG
Project Title:
Project Location: �D to M pscOr� � '"j A
Name of Building: SIkM G�'nM�tzCE PAQ� ��o sco�Rv✓ISrrJn �r7,
Scope of Project:
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
�IRi T .OSHA A)ec ne'y-7 MASS. REGISTRATION NO. 1 a(07 BEING A REGISTERED
PROFESSIONAL ANGMEEW HEREBY CERTIFY THAT 1 HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil �Architectura X _ Structural Mechanical
Electrical Fire Protection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND ,4
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professlonal Inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix 1.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY.
Signature
SUBS E O BEFORE ME THIS _ DAY OF ,2004.
My commission Expires: 2 ��
Nota IA T,
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k- BOARD OF BUILDING REGULATIONS
.,'l gLicense: CO^NSTRUCTION SUPERVISOR
Numben al 018099
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Resul�tedF�,O�f.
t JAMES M DOHERTY� '-3
93UELLS VILLAGE R8 t
3 k4rw STER ,nIH 03036ti'
Gommissbnec-
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