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17 1-2 VALLEY ST - BUILDING INSPECTION No City of Salem Ward G�,L 6/7- $ - 23FZ G6 D APPUCATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT IMPORTANT-AppftwN to complete aN Mow In seetbns:44 t; 11% N,and Of LOCATION OF eETWEE11 r\�\ P1 IgV-LS A,lp BU�.DIN3 anoea a*1a311 otos 9ueoty MON LOT BLOCK LOT 1 O SO L TYPE AND COST OF BUILDING -A/applkants Complete Paris A-D A. TtlVE, HMPROVEYEMi 0. PROPOSED UOE-FOR"DEMOUTK*r USE MOST RECENT USE 1 Ns btuWng Moassllsnllsl 2 Q Aaelmn(r tsslwnsd saw nur owof nsr 12 Wnsy ,A ❑ A.Un eA tr4.:lbtr housing uMs adds4 N.n,;h oW a 13) to Q clMrw o/r-gums O AGWU*M(S«T aV,* 13 ,�mosamw-Erlrr,aatw.t 20 ❑ WdumVW of 71 Q P1rkh g Oros. . ❑ gapak ntp4C4111wy ,. ❑ &Or M,r bOr O UF40 or drmbty- 22 srvba dart.-kook Dean S Q W.Ckkw(I-.Wkll*M d.AK s+rt nuntbn EAsr numbr d unb—___--- ot units h bu k*v in PM?a 137 1513 C4aspa Y4 Q ttMM boepilK itt.sdk= a Q MONnp(-bc m+) z4 ❑ Pub: battle otola..iottd ,s � Crean � ❑ AdouWy 7 Q Fo kftbon a,.y za Q sd"Wray.oarr sA cedond S.OWNERSHIP 17 0 Oa.-sow* 27 Q 9- m cw4m zs p Tw tau io a a k insUkdior@W.) cotocroson nonpdk zap Owr-scar+M 9 Q Pudk:(Fedn.l SW*or knel w...wd C.COST (a,tr rnts/ Mlrraaidsnlis,-Owls a dwW VOD1»d r d busdhP,04.boil pocossktg PW+L mr)tk,a attaa Watdry busdkq d ltospssL tltsmlttsly schook asootdnY aCNob4 mops_ 1 w CPasat mPtoMmanl ---_-----. a Pa1PdlW sdnd Pr"soup ks dspnrtrd atom nn■1 allbs busdkq,dlbs buadbm al nd sbW Pkart I us of saBng budding is being Urtas4 am aoPosd us. 7P a hafrtsd but not h wed ;n dl..bP,q rod ksl", b. Pkntb/q .._._.._.._.. �OV � dwdc. Flo k ale mndtlovtp aj/ : Q ONr tdaralat,v ST OF IMPROVEMEM Od D ED CHARACTERISTICS OF BUILDING - For new buildings and additions, complete Parts E-L,�demolition, 11 on Parts✓S M aN oUrers ski to IV TYPE OF FRAME F. PRWVAL TYRE OF)4EAT M FUEL G. TYPE OF SEWAGE DL9POSAL L TYPE OF MECNANYCAL sY Iwo/bsrngl as RGas 40 � PtlitofPnwawDoff% nv wr d+ro bs canur ale d t,,m 34QOs 41 Q P,MaY(mptr tank MC.) Co obonin07 ctvd Drool 37 Q Ektdncp 44 R1 `ins 43 Q 33 Q Rekdoced concmw 3a Q Cod K TYPE OF WATER SUPPLY ppl��� Wi t11a1s by an ekrgb/I 34 Q Odw-S,-.V 39 Q Other-Sp" — 44 1 Pul ffe orm WI-0 mPrry 46 Q Yka 47 � 43 PMals(will CIO") l l OelEr910Na M. DEMOLITION OF STRUCTURES: 4a rawmb.rd s+dr. ---...__..._. _ .... . . ... ..... : . ,Q Tar.v..rf few a Boar u.a Has Approval from Historical Commission been received r km 'ad W mamar for any Structure over fifty(50)years? Yes- — No_— `2080.._____.-- Dig Saw Number SQ TCW m.d ate.e4 R .. _ R rM1,iis8r Or Off-STRW P W Wei SWES Peat Control: 31. Encx"d _.._.._../_.___...._____..__.__ -- HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? u OL*b a_.._ a..___—__—___.__...__.. Yes NO L REs OnWA.eusnnro oeur WOW. Electric S, Fxlord ---------- ---- Gss FJ —__.—.__— Sewer. 54 ' mew of / DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED 0idv00" P.M.._1___...___—_ BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE TIIE FOLLOWING: Historic District? Yes— No ✓ (H yes,please entices docwrentatbn horn Moll.Corn) Conservation Arm? Yee_ No✓ (U yes,please enclose Order of Cwd do* Has Fire Prevention approved and stamped piano or applications? Yed_ No_ Is property located in the S.RA dlsMct? Yes_ No Compy with Zoning? Yes_`l No_ (H no,enclose Board of Appeal decision) Is lot grandlathered? Yes_ No_ (If yes,submit documenta*Mfd no,submit Board of Appeal decision) If new construction,has the proper Routing Slip been enclosed? Yee— No_ Is Architectural Access Board approval required? Yes_ No ✓ (if yes,submit documentation) Massachusetts State Contractor Licenses Salem License • Home Improvement Contractor a 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: S s N C) D in writing to the Inspector of Buildings v. IDENTIFICATION . To be completed by all applicants .,Wr NiYQ.IddIM.'V4TdM.SIla.(CdY end Srr. ZIP COO. TeL NM E3C, LC A !Dv,ol O( scs c.ir s x SiAdl $ce rb G6 33`j a l rs1- she e�sr zzS auk R� Mo ra�L' W SyYss �`�6932"sS �UAed x Eraraar thereby certify a pro cork co is authorized by the owner of record and that I have been authorized by the owner to make this application as his author t e agree to conform to ail IWAble laws of Nis jurisdiction. S graNre of Addr rI I Application date 3 CAM�RG( C SUSI� r� G. -S_ O DO NOT WRITE BELOW THIS LINE VL VALIDATION FOn pEpAgTMEM USE ONLY Building Permit number use craw Building 19 Fro Cxdna Permit issued BU uM LON&V Permd Fee S 00CLOWCV Land Certificate of Occupancy $ Approved by Drain Tib f Plan Review Fes $ 0 Y NOTES AND Data• (For department use) Y Aj S 0 C PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by. Completed by. I W ZONNG PLAN OWAMERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REM YARD NOTES SRE OR PLOT PLAN-For Apokw#Use O N CITY OF SALEM rt A PUBLIC PROPRERTY �.,.,.~ DEPARTMENT 'd III v-8 '4j.7;4j I-\Y: 9.78.'4,;.v,i44. i Construction Debris Disposal Affidavit (required tix all demolition and renovation work) In accordance \\ith the sixth edition of the State Building Code, 780 C'h9R section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit h is issued with the condition that the debris resulting from this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: �) r. CCc5C1C) TfJG -- 1N ) (name oChauler) I he debris will be disposed of in (name of facility) 0O,tiJ9 (add ." ,I tacilitv) Ign Wu of pcnnit.applicant _ d date - CITY OF SALEM PUBLIC PROPRERTY a DEPARTMENT i,tr, K'11 1011( 1GI 12C W,%auMo 1,^5 clu:1 • 5nu V. M.I�%%' In a l n3197- I CI. 'I73-713.9593 • 1:%s 4711-741- 1346 NYorkers' Compensation Insurance %if ldwit: Builders/Contractors/Electricians/Plumbers tinnlicant Intonn•rtion / ,��r ////���,^ r�I Please Print Leeibly Nainl:lBu.u%essil]rganvatinmindn�Juull: (4�h A��/�l l •-a�r,G city,stal .7ip �' i11it in/o3: (7$f) �a'7o - (oBS`� .%re),its in employer?Check the appropriate box: I')Pit of project(required): I.® I am a employer with�� 4. ❑ I ;un a general contractor and 1 6. New construction employees(full indur park-time).' have hired the soh-contractors 7. ❑ Remodeling 2. ❑ 1 .,,It a sole proprietor or panner- listed on the anached sheet. : ship and have no employees - These sub-contractors have 8. ❑ Demolition %corking for me in any capacity. workers' comp. insurance. q. ❑ l3tole ing addition No workers' cum insurance 5. ❑ We are a corporation and its I P• IO.❑ Electrical repairs or additions I required.] officers have exercised their tight of exemption per MGL 1 1.❑ Plumbing repairs or additions 7.❑ I am a homeowner doing all %wrk P'5 P myself. tKo workers' comp. c. 152, q 1(4),and we have no 12.❑ Ruuf repairs insurance required.) r ,:Inployevs iNo workers' 13.0 Other comp. insurance required.] •lug .yp,,aw that checks but re maul:dau fill wu the wcnou Ixiuw.Lowing their wurkcai eumpenvaiw%lwbcy udbrmatioa ' I lum.uwrcn who u,bmil this amdavit indic.uing Ihcy ire Join"all work aul then him outside cmurmaon must•uhmii a new al(davil indictingu. ch. -(-,mrxlun cb that cck Ihn box must jalwNd an adddional nha-e1.hawing the naltw of Ik sub�onlrxl,xs and fhen wurken'comp.gmhcy tnfurmantm l ans un employer that i.r pruvidbW ivurkers'cuurpanrstion in.sarvtuce jbr uty eurpluyees. Below is the pulicy and job%ile injurmuriun. C� , Q �(//� Ir..urant;e Company Valne: r __PJXAIL4, a�•e"� ""-e,�K"C1 I It licv 4 or ScIf-ins.�Liie. it:: we, ow ;uo 4 _ :Expiration Date:�Q 9 / Q luU >ite -tddress: Y --- city;5tatizip: l�Q&t)_7 r //' + 01 • -7o i .Vtacb is copy of list %workers cumpenwalion polio) declaralion page(showing life policy number and expiration date). Failure to secure co%eruge as required uudcr Scctiun 25A ul'MUL c. 152 can lead to the imposition of criminal penalties of a rife up m 51.500.00 an l'ur one-year imprisonment,as wcll is ei% 1 pcnalhcs in the farm of a STOP WORK ORDER and a fine .,fop to S250.00;t day .Ig❑insl flit violator lie ad%'t.Kl d that a copy of flits sidwinew may be lurwarded to the 011ice of I:n:>oeaI mt,of:hc DIA :or in,at uxe an crtgc %er iliul:on. l du herchy t crtify uuder the Mull'i a-nd penuhiev of perjupy that du injurtna allon provided above is true and corr ct .no:r .. _ '� ILLf /lam ! r tn,f✓. __ a 7 9 0 Il/Jia'iai rue unty. Dd not terifeiits this area, to be cunrpleled by city up town o/jirial. I Ciiv ur ffovn: _... _—. Pcrmitul.iccnse 4_ Issuing; Aulhurifp (circle fuel: i I. hoard of Iic.dth 2. Iluddin;p nl:paruncut 1. ot%u Clerk 4. Electrical laipcctor i. plumbing Inspeelor 6. Olher _ Phone it: Information and Instructions N f.,�s.ldiusetts Gencral Laws chapter I?2 requires all employers to provide workers' compensation for their employees. u I' r.u.m t to (nis .tatute, an employee is defined as * escr, pclson in the service of another under any yonnact of hire, e\pre»Jr implied, oral or whiten." .\n employer is defined as"an individual, partnership, .ssociauou,corporation or other legal entity, or any two or more it the foregoing engaged In enterprise, and including the legal rcpresenutives of a deceased cmpluycr,or the h rdCel%er of trustee of .at lltdlvldual, pwiller,,hlp,association or other legal conty,employing employees. Howavcr the owner ofa dwelling house having not more than three apartments and who resides therein• or the occupant of the J.vcllmg house of another who employs persons to do maintenance,construction or repuir work on such dwelling house o shall not because of such employment be deemed to be in employer." ,,r oi: the growuLs or hwlJing appurtenant(heret .%IGL chapter 152. §25C(6) also states that "every slate or local licensing agency shalt withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant w ho has not produced.acceptable evidence of compliance with the insurance coverage required:' Additionally, bIGL Ompter 152, §25CM states"Neither the commonwealth nor any of its political subdivisions;hall tenter into any contract for the performance ufpuhlic work until acceptable e%'idenee of cunlpltunce with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Phase 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 Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this of davit may be submitted to the Department of Industrial accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should ba relunmd to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their •If-insurance license number on the appropriate line. City or Town Officials please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the button of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. I'l.asc be sure to till in the perma/license number which will be used as a reference number. In addition,an applicant that must submit multiple pcnnit;license applications in any given year,need only submit one affidavit indicating current policy ini'ormation(if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stumped or marked by the city or town may be provided to the Applicant as proof that a valid affidavit is on file for future permits of licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a Incense or perinit,not related to any business or commercial venture (I.e. a dug license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. I Ito ,),IICC of love,rigatmms would line to thank )'nu to advance fur your Cooperation and should qua hate :my questions, please do not hesitate to give us a call. - fhe Mpaninenl's address• telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Oltfice of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/elite ACORQ CERTIFICATE OF LIABILITY INSURANCE 06/23/2 09) PRODUCER (781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 458 South Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Whitman, MA.02382 Gwen Vosburgh INSURERS AFFORDING COVERAGE NAIC# INSURED Litchfield Co. , Inc. INSURERA: Savers Property & Casualty Ins 000203 83 Cambridge St Suite 2D INSURERB: Burlington, MA 01803-4181 INSURERC: 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. INSRUDIYL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL UABIUW EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE ❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ POLICY PRO ECT- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT AM,AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) $ HIREDAUTOS BODILY INJURY $ NON OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE UASIU AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC0002104 09/01/2008 09/01/2009 1 WCSTATU- I OFR TEt H- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEMEMBER EXCLUDED? OFFICER OF CORP IS E.L.DISEASE-EA EMPLOYEE $ 500,000 it SPECIAL ALPRdescribe PROVISIONS INCLUDED E.L.DISEASE-POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DE CRIPTION OF OPERATIO,NNS/LO ATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS e`#: Valley Roaa, Salem MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Salem 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Public Properties Department 120 Washington Street BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY 3rd Floor OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORRED REPRESENTATIVE David H Mason ACORD 25(2001/08) FAX: (978)740-9846 ©ACORD CORPORATION 1988 PDF created with pdfFactory trial version www.r)dffactory.com IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) PDF created with pdfFactory trial version www.pdffactory.com Poe vc'o CITY OF SALEM ROUTING SLIP New Construction_ Certificate of Occupancy LOCATION VAII S` DATE ASSESSORS TE �— 93 Washin n St. CITY CLERK DATE 93 Washington St-1. �6'14'S�V2✓St=r�tc�`ty ok Ca.tic-�.m, PUBLIC SERVICES G S (p, AIr ATE v D orb SCVL y Vft4-€-jQ Vxatn 120 Washington St. kpiTu' &-w40 C`A-0V-q1i". /� CVAACL4t 6>x rtD Witt Y� � WATER < i� DATE AtcowaV. n — llY 120 Washington St. � m "wro?L CROSS CONNECTIO TE �� 5 Jefferson Ave PLANNING DATE gj26jOq 120 Washington St. CONSERVATION DATE d _5 o9 120 Washington St. ELECTRICAL L DATE 48 Lafayette t. FIRE PREVENTION , ATE o 29 Fort Avenue HEALTH DATE lit' 120 Washington St BUILDING INSPECTOR DATE 120 Washington St.