THOMAS CIRCLE - BUILDING INSPECTION 5
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� � o�e C�e� � PUBLIC PROPERTY
�'�� DEPAR'T�fENT
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AI\MFRLEYDR7SCULL �J
' �IAYON //S� ��/ 1?�WASHINGI'ON 5771EE('�$
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. 'I�i 9'8-7459595�Fnx:97&7i0-9846
r��PLICATION 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: i�.o..Rs �;nolc Building: �,,,,1 0��{
Property Address:MR,p � CoT � �3 4
�
Property is located in a; Conservation Area Y/N � Histo�ic DlsVict Y/N r3
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �,�.�„�, ��� `
Name: �
Address: `� G:RN.,q D2
SR.r .r� ("�A ��Jb .
Telephone: c,c� - ���_ Qo Sa
3.0 COMPLETE THIS SECTION FOR WORK IN FYICT�N� gU1LDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Changein Use New
Demolition Existing
Approximate year of Area per floor (s� Renovated
' construction or renovation
of existing building New
Brief Description of Proposed Wark:
�Jrl`�W\l`lN �N' � . .
__ . _. .___ . - __._ . _. ..
Mail Permit to: _ ---
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What is the current use of the Building? , . ,,
Material of Building? if dwelling, how many units?
Will the Building Conform to Law? AsbestosT
ArchitecYs Name
Address and Phone � �
Mechanic's Name
Address and Phone
Co�sUuction Supervisors License# C s �69�0 3 HIC Registration#
Estimated Cost of Project$ 1 a.°d° Pertnit Fee Calculatfon
Pertnit Fee $��--- Estimated Cost X$7/$1000 Residential
Estimated Cost X$1 U$1000 Commerciai
M Additional $5.00 is added as an '
Administrative charge.
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� � Make sure that all fielda are properly and legibly written to avoid delays in processing.
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��� The undersigned does hereby apply for a Building Permk to build tathe_above stated
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j 31 specifications. Signed under penalty of perjury /�
� Date 3 0 ,
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� CITY OF SALEM
��, • � PUBLIC PROPRERTY
� DEPARTMENT
KMBERLEY DR1SC011 �
MAYOR S2O WASHI1VG70N STREET � SALEM,MASSACHUSETIS OS97O
� TEL:978-7459595 � Fax:978-740.9846
Workers' Compensation Insurance Aftidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
NaTT1C (Business/Organizadon/Individual): ' � f� O e��- a ��N a^���<`� �O /�
Address: � �� A^""A �Q • .�
Co -l- - °.,O'v c�.
City/State/Zip: S �- v S �R Phone #: � c7 ( �
R L
Are you an employer?Check the appropriate boa: Type of project(required):
1.� I am a employer with 4. � I am a general con�actor and I 6. �-New construction
employees(full and/or part-time).* ha4e hued the sub-contractors
2.❑ I am a sole proprietor or pazmer- listed on the attached sheet. I �� ❑ Remodeling
' ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. � Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their �0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
mysel£ [No workers' wmp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance requ'ued.] t employees. [No workers'
comp. insurance required.] 13.� Other
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensatio¢policy information.
t Homeownera who submit this attidavit indicating they are doing all work end ihen hire outside contractors must submit a new affidavit indicating such.
IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy informaHon.
I am an employer that is providing warkers'compensation insuranc¢for my employees. Below is the policy and job site
injormation. ��
InsuranceCompanyName: �`Yr'e '�'� S. �� .
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: � �'`�^-�S �R c-�"� City/State/Zip: S��
Attach a copy of the workers'compensation policy declaratlon page(showing the policy number and expireHon date).
Failure to sewre coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal peaalties 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 violatoc Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer 'y under t ' �jury that the information provided above is true and correcL
Sienamre: /L..�/� Date: �`�3 (C�b
Phone#: � l �— � l �- 'g0 0 �
Ojfrcia!use on[y. Do not write in lhis area, to be comp[eted by city or town ojfeciaL
City or Town: Perroit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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Information and Instructions
Massachusetts General Laws chapte� 152 requires all employers to provide workers' compensation for theu emplo}�ees.
Pursuant to this statute, an emp[oyee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is de£uied as"an individual,partnership,association,corporation or other legal entiry,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal endty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction oc repair work on such dwelling house
or on the grounds or building appurtenant,therero shall not because of such employment be deemed to be an emp]oyer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency,shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of comptiance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." '
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or L'united Liability Partnerships(LLP)with no employees other than the
members or partners,aze not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this aft'idavit may be submitted to the Deparhnent of Industrial
Accidenu for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed to the city or town that the application for the permit or license is being requested, not the Deparunent of
Industrial Accidenu. Should you have any questions regazding the law or if you aze required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter the'u
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Deparhnent 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 regazding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given yeaz,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (ciry or
town)."A copy of the affidavit that has been officially stamped or mazked by the ciry or town may be provided to the
applicant as prooY that a valid af£idavit is on file for future permits or licenses. A new affidavit nwst be filled out eacL `
yeaz. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venhue
(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 not hesitate to give us a calL
The Department's address,telephone and fax number.
'� The Commonwealth of Massachusetts
Depamnent of Industrial Accidents �
, OfIIce of InvesHgadons ,
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-OS
WWW.IriBSS.gOV/d18 � .
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NOTES N/F AMENTA MESSINA DESCFIAMPS „ ���� ���
MAP 8, LOT 29 ` �� lk�' �
1. LOCUS IS SHOWN ON SALEM ASSESSORS MAP 8, LOTS 20, 21 AND 22. � '
LOCUS STREET ADDRESS IS CURRENTLY LIST AS 7-17 iHOMAS CIRCLE. 296 HIGHLAND AVENCIE � ,� 2 � �
� L.C.C. 58896/232 . NEW S�AH�4 � "9� ,7 �`
RIM=157.0 r`} ' � "
S SHONM IONSPLANN NG OARD APPROVED PLAN AS OT 3LOT 734. LOCUS r INVfn=153.0 (8"S) 3,p0'E `f �f '��'` /� reMs \�
INVout=152.5 <..+°'� ,j �i �
N6�:,i;;.�
3. THE ZONING DISTRICT UNE SEPARATING B-2 FROM R-1 WAS INTERPRETED i r�, ,, ,,�ZqB' /�g"S�
BY THE BUILDING INSPECTOR IN A MEEl1NG WITH PLDE ON AUGUST 9, 1999. ��',--.�
�::,��-,�I���.,�.. �� � �
4. PROPERTY IJNE AND TOPOGRAPHY PER ACTUAL FlELD SURVEY � ��r; � ,'�;""' � J / � N
ON-'fHE-GRWND BY NORlH SHORE SURVEY CORPORAiION. REFERENCES FOR ri - �
PROPERN LJNE INCLUDE LAND COURT PLAN �11802-E. � �C.b "`� �,.-' �g'S� i I� � '
/�� 0'� - � �,���' r'z � � � � o ..,
5. EIFVAl10NS SHOWN ON THIS PLAN ARE BASED ON CITY OF SALEM (MEAN ��Q �- , i �� S�j$p.C� / � � � 2r
SEA LEVEL) DAlUM. iHE qTY BENCHMARK USED WAS A DUPLEX HEAD NAIL N,<;!`'� � � x
IN Ui1L1TY POLE 78/1557 JUST SOUlH OF SWAMPSCOTT ROAD BETWEEN TONY "�-i� 5p2� i� EN'� � R�IPR9 � � � ¢
LENA'S AND MOOSELODGE ON 1HE EAST SIDE OF THE NORiHBOUND HIGHLAND \\\� �B�Si �PSE/ '( REP � � � ro
AVENUE (ROUiE 107), ELEVATION=132.79 (qTY OF SALEM MSL DATUM). 1� ,�..,, Y" /� SEY�R 3� F�� � � � � y
TE?APORARY BENCHMARKS HAVE BEEN SURVEYED ON iHE LAND AS FOLLOWS �89 6�"' 3�3� ��i� \ � i � � � � � Q
T B M 1: E L E V A l 1 0 N=1 5 8.8 1 P K N A I L S E T I N P A V E M E N T , 1% � I �
THM 2: ELEVAilON=133.86 TACK IN WOOD STAKE "`� �- �g"�' �6ry 36 � w � � W I
, O � q
TBM 3: ELEVAi10N=135.07 DRILL HOLE SET IN LEDGE , / ♦ TeMs i� S� `'O� `�' � � g � ,� I /
iHM 4: ELEVA710N=156.64 TACK IN WOOD STAKE i � �0 ��
THM 5: ELEVAilON=158.35 PK NAIL SET IN TREE SiUMP TBM4 � � '��^9' j /� '�,. � o � �
TBM 6: ELEVAilON=156.43 TACK IN WOOD STAKE �� � �� 6 S J,1�/T 3 �• � �
iBM 7: ELEVATION=162.40 DRILL HOIE SET IN LEDGE �� � � � S.INVo�ut=152.5 o I � �-
TBM 8: ELEVATION=167.93 PK NAIL SET IN PAVEMENT < 1 1 3 6 0 f S F ' I �
iBM 9: ELEVAilON=167.45 PK NAIL SET IN PAVEMENT \ r\ � � � �'
iBM 10: ELEVA710N=149.96 PK NAIL SET IN PAVEMENT �,�.� FfE=165.5 14 - - -^" '
iHM 11: ELEVATION=143.21 PK NAIL SET IN PAVEMENT , v � ��f\\ BASEMENT FFE=154.5 �` I r I o L �6 F R�NTS '' OT `J/
� 6. iHE LOCAiIONS OF EXISiING UNDERGROUND Ul1LIl1ES SHONM ON iHIS PLAN rdF. � ! � �� ER`� qRD
ARE APPROXIMAiE BASED ON THE BEST AVAILABLE INFORMATION AT iHE lIME � }y���� �5 i /`"� *�P,��R S Sf rBq�K
OF PREPARATION OF THIS PLAN. hIE CONiftACTOR SHALL VERIFY ALL �,�, � a � � , /
LOCAilONS AND ELEVATIONS OF ALL EXISi1NG Ui1L1TY LINES PRIOR TO ANY '\SI• sF'T� �3� � i �' �4Q / j
E X C A V A i I O N W O R K. A D J U S i M E N i S I N T H I S P L A N A N D S U B S E Q U E N T P L A N S Q F ra �f��9� �9 c�� lr�' ��. �1< �.�g.,W R ' 4 9)l6'1 � /�%
REQUIRED) SHALL BE hIE RESPONSIBILIN OF iHE SI1E CONiRACTOR BASm ON ,� t� /�. � � � � /�
AClUAL FIELD LOCAiIONS OF Ui1L1l1ES. PLDE ASSUMES NO RESPONSIBILITY �Op �,�M � Ep1< �� �INSTALL NEW �� ���
FOR�NY BROKEN (OR DAMAGm) UT1L1iY L1NES DURING SIiE EXCAVAiION �� `�'Id�.\�/ \� � ,�,� EP`'EM �t� ,>>y HYD A VE ' \ �
, AND OR CONSTRUCTION WORK.
\ 9� � O J�J � , �� � /Q' / LEDGE �P,OX SFORMER o � _ . �
7. FlNAL REOUIREMENTS FOR PAVING WAiER TRENCH NALL BE MADE AT i1ME �.� d,rF, \ 5Vn � , •d �, E� � 'P ��
OF CONSiRUCT10N. T 9 1 ���0 j� � �� s
> C,F 66 �qA :, '� �PS r�o PnvEo
D
8. CONSTRUCi10N OF iHE Ui1lJi1ES MUST BE DONE KEEPING THE ROAD OPEN � � K 5 6 � 8 �0 '�o
IN ORDER TO PROVIDE EMERGENCY SERVICES AND ACCESS FOR ABUTTING LAND �i �jBP� � j � � r
OWNERS. / „ � �PR9 39�y, � E�� Q��ya' �� �
9. DOWN iIME WHILE CONNEC7ING EXISi1NG HOMES TO NEW WAiER SERVICE FRpN �,�A , �.� �P L _ 9Ma
SHALL BE COORDINAiED NAiH INDIVIDUAL HOMEOWNERS AND SHALL BE KEPT FpO� � �` Qr� F R '
TO A MINIMUM. �5 \ �oc� � ��d� ' \GN� O r2�rn� 9��i3�
� � '�� � e'rn�
10. ALL UTIIJTY LINES SHALL BE UNDERGROUND. UTILITY INSTALLAiION SHALL '' � c, g� FD�'" r R sYra;
BE REVIEWED AND APPROVED BY THE CITY ENGINEER. � E,j ,�,�n�t `� i2'TR� �S
71. THE APPLJCANT SHALL COMPLY WITH ALL REQUIREMENTS OF THE SALEM �G ��
FlRE DEPARTMENT AND BUILDING INSPECTOR. o// ��� � � Q� 6•,�,10'� >>z
12. NO CONSiRUCT10N WORK SHALL COMMENCE BEFORE BAM ON WEEKDAYS � �6 - PLOT PLAN
AND SAiURDAYS. NO WORK SHALL CONIINUE BEYOND SPM. THERE SHALL BE %��% �
NO CONSTRUC710N, WORK CONDUCTED ON SUNDAYS OR HOLJDAYS. -O�r.a� '��% f0�
13. ALL REASONABLE ACiION SHALL BE TAKEN TO MINIMIZE iHE NEGAiIVE e�� � �����
EFFECTS OF CONSTRUCTION ON ABUTTERS. ADVANCE NOiICE SHALL BE � �UNDERGROUND ��� �� � � ��
PROVIDED TO ALL ABUTTERS IN WRIi1NG AT LEAST 72 HOURS PRIOR TO THE ° ELECTRIC,
COMMENCEMENT OF CONSiRUCT10N. � TELEPHOfJE,
14. ALL CONSiRUCi10N (MA'fERIALS AND METHODS FOR INSTALLAl10N) SHALL � MaBdEFE D (Formally Lot 3)
BE CARRIED OUT IN ACCORDANCE VNTH THE RULES AND REGULAl10NS OF THE FROM EXISTING
SALEM PLANNING BOARD, AND SHALL COMPLY WIiH ALL RULES, REGULATIONS, UTIUTY POLE On •
SPECIFlCAiIONS AND ORDINANCES OF THE CITY OF SALEM AND MASS BUILDING Thomas Circle
CODES. . ' . '
15. THE APPLICANT SHALL CONDUCT STREET SWEEPING ON THOMAS qRCLE,*�AS S ale m, Mas s ac hus e tts
DEEMED NECESSARY BY THE CITY PLANNER.
LOCAiEDCCOMPLETELY ON 7HE SITEL AND NOTIONTTHOMAS qR��HALL BE ��P�,�H �F MqsS9 Date: Decembe�r 2, 2004
02 scorr uu.i �'y PLDE #99-32 Scale: 1 = 20 Sheet 1 of 1
� PATROWICZ v�
LEGEND GRAPHIC SCALE o civi� � Owner. Thomas Circle Realty Trust
; 20 ° ''0 20 N� �s a y 9 Bridge Street, Salem, MA 01970
WHW O+VERHRAD WIRES � _ �+�
�°9 � S E pATROWICZ
s �wER r� -- _ = �S, � �,
WSO WAlER SHUT-OFF VALVE � � IN ��) �J'� ��
�M iEMPORARY BENCHMARK y 1 inch - zo it (. '(� LAND DEVELOPMENT ENGINEERING
� PROPOSED FWNDAiION `� J\ �"' 10 Derby Square, Salem, MA 01970
(978) 745-2288
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