9 THOMAS CIR - BUILDING INSPECTION No City of Salem Ward
4
APPLICATION
_ .. FOR-
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-AppBaant to complete'84 ftiffif In Sections. 4 14 114 N,and IX.
% Arabi+► ,.CJm w+5. C:R
LOCATION ao1 ,:.ra 3 smffn
OF BETWEEN K s\SA.L }iceAMSw 1»Jbw� RD"
BUILDING S (CAM STREEn iCR=511EETI
. SUBDIVISION
f �OM4S 4�\•2 fie , og' LOTS—B -. LOT
Ii
IL TYPE AND COST OF BUILDING-All app/k ants complete Parts"A-D
A. T�OF IMPROVEMENT D. PROPOSED USE
1 FOR"DEMOLITION"USE MOST RECENT USE
New WalYdno Residential., .. slbnresldentlal
2 ❑ Addidw(d issidsatle,enter number It new 12 [R 60 family - 18-❑.Amusemaa,reueetlonal
/posing unds added d any,in part A 13) 19 ❑ Cf ucK ad—re gicus
13 ❑ TWO or more family-Enter number 20 ❑ Industrial
3 ❑ Alienation Isis 2 above) - d cute
4 ❑ Repair niptecemem 14 ❑ Transient hotel,n Otel,W dermdery- 22 ❑ Parking aega Ss station .
Enlernumberdunia -
❑' s -
5 ❑ Wrecking(d muifften*realden"enter number 23 ❑ Wepfsk iWibndoral
of unifs in building in Pat A 13) 15 ❑•..Oaags _. .. 24 ❑ Oflps,bank.WdeaspMl. .
8 ❑ Moving(relocation) _ - 18 ❑ Capon, 25 ❑.Pudic utility
_ 28 ❑..Scl"library.dlr educational
7 ❑ Foundation only17 ❑ OBur-spec* 27 ❑ shores,maeemae
EL OWNERSHIP 28 ❑ Tanks,toners
8 (jr Privets(Individual.corpOraaM rpnP.M 29 ❑ OBier-SP=&
m8bkltion,BIG.)
9 ❑ Public(Federal,stift or local government i
C.COST - (Omit cede/ Nuvesider".Describe in dem7 prapoead use d buildings,e.g..food processing Plant i
macAne WM laurodry building at hospital,elementary 9dwaL secondary ached.cokes,
building
10. Ccet d 4nprovarrnent __�.--__—__�._. III �� parochial xltocl;perking garage for deparorlent store,renal dlice buildup.otibe
at Industrial plam.If use d existing building is being changed,side proposed use j
I
To be Insteffed but not inclined -
in the above cost
b. Rumbaed...._.__ .......
__.._....____.__—__ I•°�rJ a HeaSng,ate d Other(spvaor,
11. TOTAL COST OF IMPROVEMENT 1'? c c r>
ill. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L;demolition,
complete only Parts J&M, all others skip to IV
E. PRINCIPAL TYPE OF FRAME F. PRN1C-iee AL TYPE OF IIEATWO FUEL G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL
30 �Masonry(wall bearing) 35 IJ G 40 ETPublic err privateom cpany Wi Ma e be central as
31 Wood hems 38 Oil '41 ❑ Private(aepab fain,ea) cored
32 ❑ Sbuctual steel 37 ❑ EWC icsy
FL TYPE O WATER SUPPLY 44 �� 45 ❑ No
33 ❑ Reinforced concrete 38 ❑ Cob WE ihnere by an epveEo(1
34 ❑ odw_Specify 39 ❑ other-SpacdY 42 0 Public err,Mvaie company 46 D Y„ 47 61"NO
43❑ Privab(Wed.Cistern)
a DWENWNs M.,.DEMOLITION OF STRUCTURES: s• ' I
48. Numbfr Of5tOM ..-..- ._......__...._.._...__ -,:,
as TOW Square teat d%M arts. Has Approval from Historical Commission been received-'
m e,
ae fos based —
s _
i meriar ,�.4_�3.._..__._. ;for arty structure over fifty(50)years? Yes_ No_
aenens,arm r--"--'—'-'
411
Y[
So Tor tend area Sa 2-- �'`=---- 13110a%Number
r-NUMBER OF oFFSINEEr PARKING SPACES .'Peat 6ntrol:
51. Enclosed.__._._.-_._ `_...._..._._..---'---..--_--
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
Yes No
L RESID MnA�GULDMS 0-AY Watef: -• - _ - - -
- Gast-:....-
cuA____�_._____..__ Sewer:
s' "�Oef o. DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Pamr —1-----• BEFORE A PERMIT CAN BE ISSUED.
N. COMPLETE THE FOLLOWING:
Historic District? Yes— No_- (If yeas please enclose documentation.from_HISL Com 1.--
Conservation Area? Yes_ , No_ (If yes;please enclose Order,of Condrtionsr
Has Fire Prevention approved'and stamped plans or applications? Yes_. No—
Is property located in the S.Fl A clistrictt Yes_ No_ .
Comply with Zoning7 Yes No_ (If no,enclose Board of.Appeal decision)
Is lot grandfathered? Yes_ No_ (If yes,submit clocumentationX5%submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Y No—
Is Architectural Access Board approval required? Yes_ No_ (If yes,submit documentation)
Massachusetts State Contracts License# C5 ov`I Ot'3 Salem License #
Home Improvement Contracts # Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
If an extension is necessary,please submit
CONSTRUCTION IS TO BE COMPLETED BY:
�y�v��tL_ +ac in writing to the Inspector of Buildings
V. IDENTIFICATION • To be completed by all applicants
Nfine ¢} Madm addfes-Numb«,suer,cdy,and Srate ➢P Code TeL Na
DL D`Ro`o fDl-7
Owns,or J.�
Lessee
Contractor euidefs
tCet N K LXWWNa
nrehdea« AA
Ergrmt Q.7, (S» Li a A
s ,S a 753 " 7c'6
1 hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make Oft application
as his authorized eM ree to conform to all 2Rkable laws of this jurisdiction.
Signature of appli Address Ap�QQn�date
cl Ca• Rv�+R SR S .Ms! OL'LOS.+ :DLJ9la
DO NOT WRITE BELOW THIS LINE
FVL VALIDATION
Buildmg FOR DEPARTMENT USE ONLYPermit number use Gfo p
Building 19 (7d0 FreGrad�q
Permit issued "�
Building Live iaad:w
Permit Fee $
oa.,rwoY Load
Certificate of Occupancy $ Approved
by:
Drain Tile. $
Plan Review Fee $
m LE
NOTES AND Data•(For department use)
I +
t �
2� 1, It
/+ p
AJ
S2 A—
Nd Zen Acl •�Vfu�
c� S -�
9
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
VI 20NING PLAN EXAMINERS NOTES ,
DISTRICT
USE
FROM YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN-For Applicant Use
O N
CrrY OF SALEM ,
PUBLIC PROPRERTY
DEPARTMENT
hHthr It LEY WtLila.rt .
N.srxn ►Zr V AQ—&%A rcWSU r a SA test.hLtstACY a.�'t'tx 0197Z
Tbt_97L743.9595 a FAX:9M740.9946
Worken' Compensation Insurance AlMdavit: Builders/Contractors/Electrietans/PMmben
anolkant Information Please Print Legibly
NametBauncsstOrgartiratimvtttdtvtdtmq:
Address- `t G i A"N A �rZ
city/sweizip: S-R --S_r-s N* o \tt0 k: ['hose N: G, \ l sex a_ 0 o � c
Are you an empbyer7 Cheek the appropriate boa: Type of project(required):
1.❑ 1 am a empklyer wish 4. Of am a genural comr selor and 1 6. ,a,�*,�c��u�
cmployc"(full ansitor part-tine).• have hired the sub-contractors LJ
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 1 7. ❑ Remodeling
ship and have no otnptoycoo Then have g. ❑Demolition
working for me in any capacity. workers'comp. insurance
lKo workers'comp. inwtance S. ❑ We arc a corporation and its 9. ❑ t3uildiag addition
required] officers have exerciacd their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152.§1(4),and we have no 12.❑ Ruofrepa;rs
Insurance required.) t :mPloycca.(A'o workers' 13.❑Other
comp. insuran a required.]
-A-*+pp4wm am chucaa tea at mma aW Ra We am section b6low Ywrioa their wrktas'eumpouNkw puli�y ia►ama W&
I I.mt mwren who submit this enldark indkatita they an do'nd all work arse thm him molds exmrmemm mut submit a ttaw aMbrit indiadina%wk.
-C.wmnvvms Out cheek Out but nor amached;m addnionW arms showing the nave Of air and thaw wurkm'comp.paltry mfertaukwL
/um un eiaployer that ti providing workers'coarpeatadon huuranee jar my employers. Below is the polfay and Job site,
ion/mrraadU^
Insurance Company Name: __
Policy s or Solf-ins. Lie.0: _ .. _... Expiration Date:
Job Sicc .Adkcss: CityiStatu2ip:
Artach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ut.1GL c. 152 can lead to the imposition of criminal penalties ors,
fine up to S 1,500.00 and/or one-year impru mnmcnt,as well as civil pcnallics in The form of a STOP WORK ORDER and a firm
of up to S250.00 a Jay against the violator. Ile advised that a copy or this statement may be forwarded co the Office 4f
In\'Cah�'a114na of llic DIA ,'Or insurance cOKruV v'Arwition.
i do hereby rerri/y r inls u Tnmlrks ujperiury that the in/orarWlon provided above is rrae,mild correct
ii•aantrc• t""�
Date io�aq�o�
Noce 4 (9
09kiad ase onty. AO e,of write in rhk area,to be,ronpleved Ay city or fawn ojflell L
City or 'rows: __ Permit/l.leense M
Issuing Authurity (circle one): --
1. Iloard of licalth Z. Building Department I. Cityif Ott a Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
C„uWct Persou: _ Phone p:
Information and Instructions
%jassachusetu General Laws chapter 1 32 requires all employers to provide erworkers ie a another under any' compensation for their contract hiP'O�
Pursuant to this staame,an ewpfeyt defined e is deed as"...every, person in the
express or implied,oral or written."
An ate Joyw is defined as-'an individual.an aaoestoa.Corporation at other legal ennty,or any two or mote
xegoing engaged in a joint enterprise,and includi it the legal representatives of a deceased employer.or the
of the f ociation or otber legal entity,employing employees. However the
receiver or trustee
of m itdividutl.panmeabtP.ua than throe apartntenb and who maiden theteitR a the occupant tarthe
owner of a dwelling douse having not more
dwelling house of another who employs persons to do maintenance'cuoslructim or repair work on such dwelling house
or on the grounds or building appurtenant
thereto shag tent because of such employmemt be deemed to be an employer."
MGL chapter I St;25C(6)also stares thst-svu7 state or total Ifeenslag agoaey shall withhold the Issuance or
me a business or to construct buildings In the comamonweskb fir any
renewal of it license or pertain d Cps with the insurance coverage required."
apptteaat wbe bas ant produced saoptsbM svldanee of compass"ono not any of its political subdivisions shall
Additionally.MGL chapter 153,$stares"Neither the commonwealthvtrleaco of compliance with the insurance
enter into any conaaet for the par Nit worst until acceptable
requirements of this chapt
er have been presented to the contracting authority.-
Appileaatf
Please fill out the worker' compensation affidavit completely.by checking the boxes that apply o your situation an4 if
necessary.supply sub•eonnacor(t)nos)•der)and Phone nu mber(s)along with their certificacc(s)of
msonm n. Limited Liability Companies(LLC)or Limited Liability Parnteohips(LLP)with no emPlayas other than the
members or yam,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
.Accidents for confirmation of insurance coverage' Also be sure to sign and date the aMdaviL The affidavit should
be returned to the city or own that the application for the permit or license is being requested, not the Department of
Industrial Acuidens. Should you have any questions regarding the low or if you are required to obtain a workers'
compensation policy.please call die Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the apl+an•
City or Town Officials
please be sure that 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
Phase be sure to till in the permibl tense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town) A copy of the affdavit that has been officially stamped or marked by the city or town may be provided o the
applicant as proof that a valid affidavit is on file for fat re permit or licenses. A now affidavit must be filled out each
icense or permit ring related to any
(ice a dog�license or permit to burn leaves a ham owner or citi=n is be�)saidg a 1person is NOT required o complete this at'tidavus or m'nercial venttue
I'hu Oflix of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OM"of Invesdpdew
600 WashingtM Street
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
tcvi.cd i-2G-US www.num.gov/dia
ACORD CERTIFICATE OF LIABILITY INSURANCE 1 06/D4/`°�2007
PRODUCER (603)352-2224 FAX (603)357-1217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Kapil off Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
417 Winchester Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Keene, NH 03431 `
Joyce Torrey INSURERS AFFORDING COVERAGE NAIC S
INSURED Buy Modular, Inc. INSURERA: Liberty Mutual Insurance
DBA: Adam Oubriske INSURER B:
PO BOX 511 INSURER C:
Keene, NH 03431 INSURER D:
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 IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR MD TYPE OF INSURANCE POLICY NUMBER POLICY EFIMMFECTIVE POLICY EXPIRATIONNLIMITS
GENERAL LIABILITY rGonM_ DAM MMIDOTY1 EACH OCCURRENCE E
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
CLAIMS MADE OCCUR MED EXP(Any one Person) $
PERSONALAADVIWURY $
GENERAL AGGREGATE $
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-GOMPIOP AGO $
POLICY PRO-
JECT LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accideot) $
ALL OWNED AUTOS BODILY INJURY
(Per Person) $
SCHEDULED AUTOS - l
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC E
AUTO ONLY: AGO $
EXCESSAILIBRELLA LIAIRMY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE E
RETENTION $ $
WORXERS COMPENSATION AND WC531S358666016 04/01/2007 03/09/2008 I TwcgYLrATui
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT E 100.00
A ANY PROPRIETOR/PARTNEWEXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100,00
B Yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 509 0D
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES lEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVWONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLXXES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE MUM INSURER WILL ENDEAVOR TO MAIL
Avis America 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOME LEFT,
Attention: Theresa Harer BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Henry Street OF ANY IOND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Avis, PA 17721 AUTHORED REPRESENTATIVE /1 T
Joyce Torre JOYCE �
ACORD 25(2001/08) ®ACORD CORPORATION 1988
THOMAS CIRCLE 166-07
COMMONWEALTH OF MASSACHUSETTS
_ CITY OF SALEM
1GIS#: 10840 -
IMap: 8
Lot: FOUNDATION PERMIT
Lot:R
0734
PerFOUNDATION
CateFoundation Only
Per166-07 PERMISSION IS HEREBY GRANTED TO:
Project# JS-2007-0239
Est.Cost•. $18,000.00 Contractor: License:
eG Charged;$1.,31.00 TB20 ANTHONY
iBalanceDuei:.$.00.. ^,Owner.' AnthonyTirc _
#of Fixtures j ,Applicant: Anihony Tiro
DigSafe# ?— AT. THOMAS CIRCLE
juseGroup
ConstClass
ISSUED ON: 30-Aug-2006 AMENDED ON: EXPIRES ON: 30-Jan-2007
TO PERFORM THE FOLLOWING WORK:
FOUNDATION ONLY
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF
ITS RULES AND REGULATIONS. (/�
SignatuFe:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2007-000297 30-Aug-06 4264 3 L.00
GeoTMS,P 2006 Des Lauriers Municipal Solutions,Inc.
�I
CITY OF SALEM �-
ROUTING SLIP
NEW CONSTRUCTION g e
CERTIFICATE OF OCCUPANCY
LOCATION: •� DATE 1 2I a `t`2
APPLICANT:
ASSESSORS
FRANK KULI wTE: D
(93 Wultington SCITY CI ERK
CHERYL LAPOr**r Q �iiidGl %0/ � DATE: �� U
(93 Wuhington Street)
PUBLICESERVICES DATE:
6 0
`1 l"• ZS
(1.,d Washington Strut)0 Floor p..,:a.e V✓(.✓4} e�,*t evt..el
WATER
DOTPIE THIBODEAU �y /A�hn17o .. DATE:-owe
(120 Washington Street)4°Floor
CROSS CONNECT SUPERVISOR /
BRIAN THIBODEAU /y DATE:� a 7� O 7
(S Jefferson Avenue)
PLANNING Iy ZY� o�
- - L— DATE:
(12u Washington Street)34 Fl�oot
CONSERVATION COMMISSIgIy- DATE:
/A
n //�V /o zs
11U'2� �u�iL2S (120 Washington Street)31d Floor
ELECTRICAL
JOHN GIARDI DATE:
(48 Lafayette Str
FIRE PRE _ J
EN GRIM
DATE: / ,L G�
(29 Fort Avenue)
HEALTH
JOANNE SCOTT / DATE:70 '07
(120 Washington S )4°Floor
BUILDING
THOMAS ST. PIERRE DATE:
(120 Washington Street) oor