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14 SYMONDS ST - BUILDING INSPECTION
I`Y-OF SALE- - ` PUBLIC PROPERTY DEPARTMENT KI.%MFALFY DRISCOLL MAYOR 120 WASHINGTON SMEEr S•LIEK MAssncxt;sti-rs 01970 I'm 978-745-9595 6 FAIL 978-740-9946 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 Y/N N Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land V j/UI=C%N C__ © R P Name: _ Address: cj SD e-1911?2 t Wi-C-- .5�. Cf77/'1 Tj T i T7G� M/�, Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN FYIATING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: 15v/L0 7-10Rr r® ,k--lTcifCH1, e-rPJF.4Y' 7 Ixj6 ' ;e457Ho DAL v r'5 ii¢i E5 j3A-7-t+ 200�y Mail Permit to: What is the current use of the Building? Material of Building? 4e-I,2f2 12 If dwelling. how many units? Will the Building Conform to Law? %—�7 Asbestos? Architect's Name Address and Phone ( j Mechanic's Name Address and Phone Construction Supervisors License# & CZ60 HIC Registration# Estimated Cost of Project$ Permit Fee Calculation Permit Fee$ 2 0 -- Estimated Cost X$7/$1000 Residential - ----- -- _- — — Estimated Cost X$11/$1000-Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date iil 2—D 17 of o� a w s a - - off' -- �v— nr --- -_..- --- - --- ---- ------- - -- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT NAroa IM VAsmer rortStssrr•ULD4 tlAStaaunsT[SaI970 let.:97W4$-VM•FAX W11,740.9N6 Workers' Compensation Insntraace Affidavit: Bupd&WContracto Aptidnat Information M Print r.tee IV Name l ' : Address: City/StUNMP:2 9,1 0- V 7—AA i 0 b Phone* Are you in empteyari Cbeck the appropriate boss 1.[a I am a employee with_ _/ 4. ❑ I am a general com adw and I �'W� ,�( : employ=0"and/or part-time).• have hired the subcoonectom 6 ❑New construction 2.❑ 1 am a cola proprietor or parmao- listed an the attached thee.t 7. ❑Remodeling ship and have no employees Theta ads-castnclas have t. ❑Demolition working tar me in any eapaciry. workera'comp innnasee. 9. (No workem'comp insurance !. ❑ We am a corporation and its 1. ®Buildicaling�mm+�l oelicam haw eaemtsed their ❑ repairs or additions 3.❑ I am a homeowner doing an work right of emotion per MOL 11.0 Phtmm"repairs or additions Myself (No workem'comp, a 132.#1(4).and we have no insurance l t smPbYeos.(No workms' 12.❑Roofnapalm comp•insurance l 13.❑Other 'Aar sw .tuw drat dmb bos at moo sew doom er"Cora Lwow Aming amlr ta�6a tiomeowaas cote one"Ass eladtsit taelueog 6Y an doing an role andsw td"eiwidn em tC it w6elt awaa�a(t wtraetar IYn dark ode tat Cent raoAd mommommunmen�eddttloed mire.�6rwlea era eta oeam wbeaehae oo d emir wabua'tanR teatmatleL /era ax raspbye►tArat LorovJd/nl workers'eowOswwdow lajorwsBaa laaareacijor nr3,ewPloyesa Below/s dboo&7 ewd j.&dy Insurance Company PolicY N or Self-ins,Lie.W 9?e C �p 21 - Ft-o S Expiration Job Site Address: /y 3`%�1 pN D 5 S % Ciry/Shtellip i/1 L r H NIA Q Attach a copy of the worker.'compeasadon policy declaration Page(showing the policy number and**ra ton daft). F'hue to seeuro coverage as requited under Section 25A of MGL e. 132 can lead to the fine up to f 1,500.00 and/or one-year ins imposition of criminal penalties oft prisonment,as well as civil penalties in the fan of a STOP WORK ORDER and a fine of up to f230.00 a deft against the rriolamr. Be advised.bat a copy of dos statement may be forwarded to the Ofte of InvettigadOw of the DIA for insurance coverage verification. /do kereby cardAmordo Raw cal peao/rbe ojoer*7 rim rib infamedow I f Moulds!oboro 4 trra and correct Signature* A Dtw, 6 _ Phone Ah Sa —�G y—r 4 S� FBoairrd e owlJt Do am wd&in JAh oreo,to be eosnolmed by dry of rows o, k&j ws: Permit/Ldeeme N thority(circle ones I. f Health 2.Building Department 3.CitY/row Clerk 4.Electrical Inspector S.Plumbing Inspector Contact Person: Phone N• information and lnstrucuum apter 132 requirte tm etnplaY 00 provide warless'compensation fer their nmplaYxs. Mass chuseas defied as"..•evert pasts is the service of another under any ennead General Laws chap ofhue. -' Purwant to this statum an n+t AYm express ter implied.oral or wntom." woeiadas.ccrpoadns or other legd enntY,of any two or mots An 910WAY'r is defined a"an individual.parmnd including rR��the�Was of a chased employee However the of the foregoing misted m a}wa mmtPt�! a>soeisdns ter other legld entity.employing receiver a trusty of an utdtvfdud.partaershtP. who resides thmei4 or the occupant of do owner of a&wellies#buss having not n°oa dus tierce spareoaent wodt as such dwelti g bons dwaWnS hoq�a of asotha who emPi°ys pt�" employment deemed to be as amptoyer-" at on the iICAND&or buildimi aPPue°d°t widdold the issuance or M L chapter 132.42SC(6)also state°that"„'cry state sr toed sffeseya W esswesWW*fer nttPfer aW resewd of a tlasss or Paw"to opera• �eeallett"� apparset wbe bas act predsead acceptols with the lessrssa cavern@ span commonwealth enter tto an.MCC�chapter�parkraws"ofpuhtic work kmul' acceptable eY1t° �off�with the insurance enter ereqWmmsm of this chapter have ham Presented to the contracting attt eft" *WlAppitnnd the boxy the apply tn Yw sitnatias sad.if Please fill out the wodwe a t a�i d vit coM YPhone numbers)along with their cardftc"Ks)Of the is •°1WPhl (LLQ at Limited Liability Partnership`(LL>)with 0o e�loyess am es have members as Purulent, a no t rc*jit"to c� coutpustaties�acanw If as[LC or ladnsorid a��d z Be advised that this affidavit may be submitted to the Department A date do saWava. The affidavit_ ��for con made°of issuance cavetsge. Ado be sane sign is being requeaa4 not the Depa unan of be reaunad to the city at town that the spplicstim for the i do law er if you are requited ro obtain a workan todoetrid Accident. Should Yon have any questio°s regarding compmados Policy.Plow call the Depltomant It number Hated below. Selfinwred atmtpanies should eater their lf-innusscn lien«mtmbt°s the lies: se City or Tows OfBeiafa ded a space at the bottom Please be nue that the affidavit is complete and Panted legibly- The Department Pam^ of the atRdavit for you to fill out is the event the Office of Investigations has to contact you regarding the aPP Please be No to fill in the parn"license mtmber which will be used as s m only srcnce number.o In addition i ic sting cot applicationsin any given year,need only submit one affidavit indicating current that must nrbmit ntutdpte ere the applicant should writ"all iacadans in_,__(city at policy. (if Owes y)and under"Job Si"Addrasd' or merited by the city or town may be provided"the town)."A copy of the dfida that has hem officially stamped of liunsea A new afLdrvir must M filled out tech applicant a proof that a valid cidz=affidaviti u m file for pencils not related to any business or commactd vacs us ear.Where a passe Darner at citizen is obtaining (i.e. a dog license cc Parrott to burs leaves cm)slid Pam is to NOT M"ted complete this affidavit. Office dbtvesdgsdeos would like"thank you in advance for your cooperadou and should you have say gserdous' The please do net baits"to five us a calL The Depsrommt's adducts.telephone and feu numbers Tde CMMMWUM of 1b &"W nseas Np racca of ladt>s1nd Amdenri 09ke of In"W99110102 600 WL*09"Street Best^MA 021 It TeL M 617-727.4900 Cd 406 at 1477-MASSAFE Fax N 617-727-7749 Revised 5-26-05 Www,mgwpv/d11 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MM/DDIYYYY) URBAR01 12 28 06 PRODUCER .. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CHARLES J COUGHLIN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INSURANCE AGENCY HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 DINLEY ST. P.O.SOX 10 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DRACUT MA 01826-0010 Phone: 978-957-3588 Fax:978-957-6612 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Ins Cc 14788 INSURER B. Americain Zurich Ins Robert Urbanek dba INSURER C: Urbaco 41 Grove Avenue INSURER D: Dracut MA 01826 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MWDD/YY PDATE MM/DDm LIMITS GENERAL LIABILITY EACH OCCURRENCE $500,000. A X COMMERCIAL GENERAL LIABILITY MP-190-021 02/18/06 02/18/07 PREMISES(Eaoccurence) $500,000. CLAIMSMADE (.. . 00CUR MED EXP(Any one person) $5,000. PERSONAL B ADV INJURY $ 500,000. GENERAL AGGREGATE $ 1,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000. POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANYAUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ` ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ _ $ VIU- WORKERS COMPENSATION AND X TORV LIMITS ER B EMPLOYERS'LIABILITY 9736A26-A-05 06/13/06 06/13/07 E.L.EACH ACCIDENT. $100,000ANY PROPRIETORIPARTNER]E B OFFICEWMEM ER EXCLUDEDP ECUTIVE E.L.DISEASE-EA EMPLOYEE $ 10 0,0 00. Ryes,desuibeunder E.L.DISEASE-POLICY LIMIT $500,000. SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CARPENTRY CERTIFICATE HOLDER CANCELLATION SALFI,M SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Building Inspector IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 120 Washington Street Salem, MA 01970 REPR SENTATIVES. AUTM D REPRES NT TIV ACORD 25(2001/08) ©ACORD CORPORATION 1988 1 > � guard of Building Regdi OR,. . HOME IM 1 MENT CONTRA1p7 ROVE 2007 � TyDkPll , t URBACO, + n ROBERT URBAN '^ VE.AVE w ' - �.. 41 GRO " ' a- Adudnlslrsto!' DRACUT.IAA ye G.REGULATIO�, � 4 0AROOF BUILDIN SUPERVISOR + E' B CONSTRUCTION 4V 'I License p15110 Number CS., �` 1g 05k19f a' 250'15, 1 I BiAhda - Tr.no: y�ExP+�s 05l17120p8; -. i . ROBEROVE.A E ANEK .�--- 1�GR 0102&.--' c-M!" sioaeG 4 x DRACUT. MALL CrrY OF SALEm PUBLIC PROPERTY DEPARTUEWr Stares +sots70 Construedo� Dcbcls ®9sPosat AfBdsvit (cegeiead itw ill dmoadm sod MwAdft wadq is with thesMn eo s w � 6 Cadt 7W CUI SWIM l IIJ B Mdt is isu d VGA dr aotdudat do dr ddwk mmaft lt,oez this wort"be dryow d of i,s P , Itoenetl wets dyad s dead by tl(Lil.e ili.st�►. z1w.dells wiu be t:att�poeoed byt lad dbaM�1 Tha dobds will be dispo"d atilt: (eamr a[IxiliM (mow a!heilit» utt+w�•dv+�e�oY��t 1 _ dw RED- - - EXISTING ISTING HOUSE OPEN WALL AND INSTALL 2 1-3/4" X 12" LVL HEADER 0 Q Q 01 16'-0" 2" X 6" RAFTERS 2" X 6" CEILING JOISTS R-30 FIBERGLASS 1/2" CDX PLYWWOD INSULATION VINYL SIDING R-13 FIBERGLASS INSULATION TYVEK OR EQUAL 1/2" CDX PLYWWOD 2" X .4" STUDS R-19 FIBERGLASS 3 2" X 10" P.T. BEAM INSULATION 7 _ 0" 2" X 8" FLOOR JOISTS 6" X 6" PT POSTS 0 , "BIGFOOT"' FOOTINGS W/SONOTUBES -4 L ! �o ,o o syVioNvs 0 A P 71 PLAN OF LAND . - 3 Lo-r tz- N I HEREBY CERTIFY THAT THE SHOWN HEREON PREPARED FOR 132S LOCATED ON THE GROUND AS SHOWN. ��P�taowregas tr SCALE : 1 " _ ?�� Zb%(O. FREDERIooaM. °K RURAL LAND SURVEYS lA D6 el .27 78 130 CENTRE 5T. - DANVER5„MA. DATE FREDERICK P.L.5. 7E