THOMAS CIRCLE - BUILDING INSPECTION (2) . -
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DEPAR'TNiENT
I:I�6leRlEY DRIS(:OLL
MAYOB 12O WASHINGTnN SIREEI'�J
ni.�.�t,�csncti�st�-[s 01970
. l�i 9'8-7i5-9595� Fnx:97&740-98q6
APPLICATIOI�I FOR THE REPAIR RENOVATION CONS�RUCTION
DEMOLITION. OR CAANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION � � � ' �
Location Name: �,�„�; c;2o�� Building: c.,�,d oH�� • ?
Property Address: MR,� 0 �o�- o�3 s
�
Properly is located in a; Conservation Area Y/N � Historic DlsUlct Y/N �
2.0 OWNERSHIP INFORMATION
2.1 Owner ot Land `
Name: A�+�,» '-T: .o �
Address: �Q
�1 C�:q��^��i
Sq., ,,� ��•R O���ob
Telephone: --- c,��- �i a• g o g p
3.0 COMPLETE THIS SECTION FOR WORK IN Fx�criN� BUILDINGS ONLY
Additian Existing
Renovation Number of Stories Renovated
Change in Use NeYy X
Demolitian Existing '
Approximate year of Area per floor (s� Renovated
construction or renovation
of existing building New
Briaf Description of Proposed Work:
F,,,ti��-�.�,.� oal .� �
__ _ _ _ - -
Mail Permit to: - - . _
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. ,_•�--
What is the current use of the Building7 . .
Material of Building? �f dwelling, how many units?
Wiil the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone � �
Mechanic's Name
Address and Phone
ConsUuction Supervisors License# �s o�9 0o s HIC RegisVation#
Estimated Cost of Project$ ���'�° Pertnit Fee Calculation
Permit Fee $ 13 / Estimated Cost X$71$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Adminisirative 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 bove stated
specifications. Signed under penalty of perjury /� �
Date �j d
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�,= � CITY OF SALEM
�• PUBLIC PROPRERTY
DEPARTMENT
1:IMBERLEY DRISCOLL
MAYOR 120 WASHQ�IGTONS'CREET �SALEM,MASSACF[I�SETTS01970
H¢1
TEi:978-745-9595 �Fnx:978-7a0.98a6
Workers' Compensallon Insurance Aftdavit: Builders/Contractors/EI P�ease Pr nt L¢blv
A licant Information
Name (Business/Organizarion/Individuaq: I � f O
�evLa C��.,a��-�� �oiJ
Address: � � A^�^'A �a ' �
City/State/Zip: s v �g �`�'R Phone #:
�01�- 7 ( �� �0'v �
�re you an employer?Check the approprlate boz: Type of project(required):
" 1.['. I am a employer with 4. � I azn a general contractor and I 6, �.New conswccion
employees(full and/or pact-time)! haVe hired the sub-contractors � Remodeling
listed on t6e attached sheet. 2 �
2.[� I am a sole proprietor or pazmer- These sub-conhactors have S. ❑ Demolition
' ship and have no employees workers' comp. insurance. 9, � Building addition
working for me in any capacity.
9, � We are a cocporation and its
, [No workers' comp.insurance 10.0 Electrical repairs or additions
required.] officers have exercised their
ri t of exemption per MGL 11.❑ Plumbing repairs or additions
3.� I am a homeowner doing all work �
mysel£ [No workers' comp. c. 152, §1(4),and we have no 12.� Roof repairs
�' insurance required.�t employees. [No workers' 13.0 Other
comp.insurance required.]
-pny applicant that checke box#I muet elso fill out the section below ehowing their workers'compeneetion policy intormation.
��Homeownen who aubmit thie aftidavit indiceting they am doing al�work end then hire outaide conlrectore must submit e new efCidavi�indicating such.
"Cont�octora that check thie hox muat ettached en edditionel eheet showing the neme of the sub•conuactors end their workers'comp.policy informadon.
f am an employer that ls providfng workers'eompensotion insuranee jar my emp/oyees. Belnw�s the pol�cy and Job stte
+njor mation. ��
n�w ance Company Name: �`r�'� '�N� �� .
Policy k or Self-ins.Lic.#: Expiration Date�
Iob Site Address: � �O"-�S � rt`-C� Ciry/State/Zip: S'K�
Attach a copy o(the workera'compensadon policy declaradon page(showing the pollcy number and eapirarion dete).
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$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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby cer ' under a t es of that the injormatlon provided above rs erue and correct
Si namr
D : ��J 3 ��t�
Phor.e# � l �� c7 t �' �0 0 �
�jficia[use only. Do not wrire in thts area,to be completed by eJry or town ojfrciaL
,
I PermiULicense# —
City or Town: —
Issuing Authority(circte one):
1. Board of Health 2.BuildMg Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#:
NOTES
GRAPHIC SCALE ��`�%'��
1. LOCUS IS SHONM ON SALEM ASSESSORS MAP 8, LOTS 20, 21 AND 22. � � �
LOCUS SiREET ADDRESS IS CURRENILY LJST AS 7-77 iHOMAS CIRCLE. z° o io 20 �� � �
2. LOCUS IS SHOWN ON LAND COURT PLAN �11802-58 AS LOT 735. LOCUS I�� r ' �` J�"" \
IS SHOWN ON PLANNING BOARD APPROVED PLAN AS LOT 4. � IN � � �,.--�' c,y.
3, iHE ZONING DISTRICT UNE SEPARAi1NG B-2 FRQM R-1 WAS INiERPREiED 1 inch = 20 tt q2 �"`���� ���
BY 1HE BUILDING INSPECTOR IN A MEEiING WIiH PLDE ON AUGUST 9, 1999. , NEW SMH/J5 - �a3� " 4`C5 /
RIM=161.8 /� 0
4. PROPERTY IJNE AND TOPOGRAPHY PER ACNAL FlELD SURVEY R25 ,� �� "r�'�
INVn=156.0 (8"S) 69; 5' \,�� �
ON-THE-GRWND BY NOR7H SHORE SURVEY CORPORAiION. REFERENCES FOR - N ,. �" '. --'619 °�
IIJVout=155.4 �-, ,,- � � `ti��
SEAPLEVEL uDAiUM. UTHE CNTY BEN H ARK US DOWAS A DUPLEX HEAD NAIL �� - '!�� ,�Q� �� ' ,�� \
5. ELEVATIONS SHOWN ON 'fHIS PLAN ARE BASED ON CITY OF SALEM MEAN y� �
IN UTILITY POLE 78/1557 JUST SOUhI OF SWAMPSCOTT ROAD BETWEEN TONY { SEWER WYE � 5�� �` �C � � � `�;;,
LENA'S AND MOOSELODGE ON iHE EAST SIDE OF iHE NORTHBOUND HIGHLAND g CONNECTION� �r-�"'�' �8 \ �M� ��/ `C';,�
AVENUE (ROUlE 707), ELEVATION=132.79 (qTY OF SALEM MSL DAiUM). z $�X s�x 8� r�^'�!"'' � � �� / �
� INV=154.68 ,- ' � � I \ � � / ��\.
TEMPORARY BENCHMARKS HAVE BEEN SURVEYED ON THE LAND AS fOLLOWS: - i� �� /� `'O.� ' / ��
THM 1: ELEVATION=158.81 PK NAIL SET IN PAVEMENT � � � ^r� � n I �$•5� g�% SEMEN / \ � � �
THM 2: ELEVATION=f33.86 TACK IN WOOD STAKE " % h1 i � � EP � � � ���\ �b
'fHM 3: ELEVAT10N=135.07 DRILL HOLE SET IN LEDGE �r� � �� •� J2�� � i� 120� 5E`� �,�$pG� �� J, �� �
iHM 4: ELEVATION=156.64 TACK IN WOOD STAKE o ) � W� 5 i \ �" � \ Ri
iHM 5: ELEVAilON=758.35 PK NAIL SET IN TREE S1UMP ,� t�� %��, ' TBM6 wo \� /2� � �/ PR.�PR9� i �P\d`�� rLo
iBM 6: ELEVAT10N=156.43 TACK IN WOOD STAKE , \ /�p0_,, ; i �. R �
iHM 7: ELEVATION=762.40 DRILL HOLE SET IN LEDGE � y •33 . ,--j" i� + fO�j�� F �// -�
' TBM 8: ELEVAT10N=167.93 PK NAIL SET IN PAVEMENT N v,�, `-'' .5�� �N 3��� 9f��? p
iBM 9: ELEVAl10N=167.45 PK NAIL SET IN PAVEMENT ,.��;�a�298 ,i8 y ��� � � c" J+O�. p
1BM 10: ELEVA110N=149.96 PK NAIL SET IN PAVEMENT " � iW Q �� �y� p�
_.�-. ,
THM 11: ELEVAiION=143.21 PK NAIL SET IN PAVEMENT �",o m � S.INVout=155.0 \ � '� � �i
6. THE LOCATIONS OF EXISl1NG UNDERGROUND Ui1L111ES SHOWN ON THIS PLAN / '�c+�i ni " 5 �/\ f � g��E
ARE APPROXIMATE BASED ON THE BEST AVAILABLE INFORMAl10N AT THE TIME o, �� ' �� / �( � O�t
OF PREPARAiION OF THIS PLAN. iHE CONTRACTOR SHALL VERIFY ALL � � � Z ¢ � A •1
LOCAl10NS AND ELEVATIONS OF ALL EXISTING UTILJTY LINES PRIOR TO ANY ( � � r W ' T /'�1�1 A /��P'� / •G 1
EXCAVAl10N WORK. ADJUSiMENiS IN THIS PLAN AND SUBSEQUENT PLANS IF Y � 1�1�1 1 �t � �j
REQUIRm) SHALL BE iHE RESPONSIBIUTY OF THE SI7E CONIRACTOR BASm ON ' W r- ',2,133fSF � qy�� /��J
AClUAL FlELD LOCAl10NS OF UiILJT1ES. - PLDE ASSUMES NO RESPONSIBILITY I �- O
FOR ANY BROKEN (OR DAMAGED) Ui1LJTY L1NES DURING SITE EXCAVATION I � � FFE�169.0 � P� rJ,
AND/OR CONSiRUCiION WORK. � q a GF=168A ' ;� � 4,� I� �
Q BASEMENT FFE=158.0
7. FlNAL REQUIREMENTS FOR PANNG WAiER iRENCH N7LL BE MADE AT TIME / W � �o.s" M //,``'~� / �SEWER STUB
OF CONS1RUCilON. � q � / �O MARKED WITH PRESSURE
v� � � / 4 TREATED 2x4 ���
8. CONSiRUCT10N OF THE UTILIIIES MUST BE DONE KEEPING iHE ROAD OPEN � � � � � tio � INV=159.92(8'S)
IN ORDER TO PRONDE EMERGENCY SERVICES AND ACCESS FOR ABUTTING LAND I o
OWNERS � � / �'O�
I ��' EXTEND S"WATER MAIN N/F SUSAN M. HOWLAND
9. DOWN TIME MMILE CONNECIING EXISi1NG HOMES TO NEW WATER SERVICE � � � MAP 8, LOT 23 & 24
SHALL BE COORDINATED WIlH INDIVIDUAL HOMEOWNERS AND SHALL BE KEPT � � e� � ' TO PROPERTY LINE
TO A MINIMUM. �4�, - _�` INSTALL CAP AND 5 THOMAS CIRCLE
���� � - F ls .. \ / BLOW-OFF VALVE L.C.C. 6 6 5 3 1/3 21
BE EVIEWED AND�APPROVED BY THE�qTY ENGINEER.UTY INSTALLATION SHALL I �o �����6 R�Nt �AR��� �
i / . P�� _ � ` rBA�K // /�
11. iHE APPLICANT SHALL COMPLY 1Mh1 ALL RE�UIREMENTS OF iHE SALEM ��
FlRE DEPARiTAENT AND BUILDING INSPECTOR. „� � � R�48,5� � �� �
12. NO CONSTRUCiION WORK SHALL COMMENCE BEFORE 8AM ON WEEKDAYS � � �8 W ��1� '� � ���� P LO T P L��
AND SAlURDAYS. NO WORK SHALL CONIINUE BEYOND SPM. hIERE SHALL BE ���" � O
NO CONS1RUCilON WORK CONDUCiED ON SUNDAYS OR HOLIDAYS. �INSTALL NEW � ��//�j �
E�� ��Z� HYD VA VE �%// fOf
13. ALL REASONABLE ACT10N SHALL BE TAKEN TO MINIMIZE iHE NEGAi1VE �_d""'�� TRANSFORrdER ti � � ��//�
EFFECiS OF CONSTRUC710N ON ABUTTERS. ADVANCE NOi10E SHALL BE �''' /a °� �mce 60X 'A a
PROVIDED TO ALL ABUTfERS IN WRIIING AT LEAST 72 HOURS PRIOR TO iHE gy �� I e o
COMMENCEMENT OF CONSTRUC110N. / PS�N � �O PAVID AREA
14. ALL CONSTRUCiION (MAiERIALS AND MEiHODS FOR INSTALLAiION) SHALL Q� ��� (Formally Lot 4)
BE CARRIED WT IN ACCORDANCE N1iH iHE RULES AND REGULATIONS OF iHE \
SALEM PLANNING BOARD, AND SHALL COMPLY WITH ALL RULES, REGULATIONS, �, �P,� 1 L � ��8 1 On �
CODES.CAiIONS AND ORDINANCES OF THE CITY OF SALEM AND MASS BUILDING � R = 9 0 Thomas Circle
`, \ O "�� '9 r�s �.
15. iHE APPLICANT SHALL CONDUCT SiREET SWEEPING ON THOMAS CIRCLE, AS �O R�G`` � '�� � e'rn� N S a le m, Mas s ac hus e tts
DEEMED NECESSARY BY iHE CITY PLANNER.
16. ALL CONSTRUCTION VEHICLES LEFT OVERNIGHT AT iHE SIiE, SHALL BE � / � � i� , Date: December 2, 2004
� LOCATED COMPLETELY ON iHE SITE AND NOT ON iHOMAS CIRCLE. i>>>2� D p�.�H OF MqS A = .
�-+ bb�i�� � �ry,�PA�� ��Z'r-fcym PLDE �99-32 Scale: 1 20 Sheet 1 of 1
LEGLi ND , N Owner. Thomas Circle Realty Trust
�/� ciw� � � 9 Bridge Street, Salem, MA 01970 '
OHW OVERHEAD WIRES //���, I " 9 . 36 6 ti
"' """'°� � '"�"�% � ' � ���� PATROWICZ
wso w� sHUT-o� vnwE v,� S NA � LAND DEVELOPMENT ENGINEERING
iBM iEMPORARY BENCHMARK
� PROPOSED FWNDAiION ;,= a.., 10 Derby Square, Salem, MA 01970
(978) 745-2288
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