30 WARREN ST - BUILDING INSPECTION �
E�--e���t `�
' `'' '� �J�0��7 PUBLIC PROPERTY '�
DEPART'NiENT a'
�
1:1�MEILLEY DRISI'Aril.
N.�ro� l�W,�wtc�crotu S7a�'e�"'��S,��sncH�st�'ts 01970
Ifi 97&74i9595� Fex:97&7�0.9&t6
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTIIVG
STRUCTURE OR BUILDING
. 1.0 SITE INFORMATION
Location Name: 8uilding:
Property Address: � v _� �� � �� S� �,�
property is located i� a; Conservatbn Area Y/N HisWric Distrid Y/N�_
2.0 OWNERSHIP INFORMATION
2.1 Owaer of Land �
Name: 20���.z- l . `�-�c �t-u����
Address: � ,,�a�QzcQ�S S c— �' S
7elephone: ZS 5 g � S � '7
3.0 COMPLETE THIS SECTION FOR WORK IN FYiaTiN� BUILDINGS ONLY
Addition Existing yJ
Renovation � Number of Stories Renovated
Changein Use New
Damol�t�:.n Existing •200o s�
Approximate year ot Area per floor (s� Renovated �.b s �_-
construction or renovation
of existing building New
RriPf Description of Proposed Work:
i3P.��oo �-1 � l� �U D ��
. _ _ - -----
-- --- Mail Permit to: ��� a�-'z. �- ' , hw �•r�s� Sc._
What is the curtent use of the Building? � `-� � �'-���— ,
Material of Building? w m� � �f dwaliing, how many units? S
Will the Building Conform to Law? "{ �%S Asbestos�
Architect's Name f � �`�T ti �~ .�� `� � i. � •
Address and Phone t � 1�.3��±-�-,'T'�"r' G�^"�� �
9� 8 2.�3 3-"i �'��
Mechanic's Name �s�r�;��r.c -, �'��, w-s n.� �l, u vb�� �:.�c --
Address and Phone `� � � 5 `� 4 � 5 l �
A fL G w• "��.� v-��,c W�{
Construction Supervisors License# �3 3 2 HIC Registratlon# y�� � �
Estimated Cost of Project S o a o , � � Pertnit Fee CabulaUon
PermR Fee S ��� EsUmated Cost X S7/51000 Residential
�U� � Estlmated Cost X$11/$1000 Commercial
M Additional $5.00 is added as an
Administrative charge. -
Make sure that all fields are properiy and legibly written to avoid delays in prxessing.
The undersigned does hereby apply for a 8uilding Permit to build to the above stated
specificationa. Signed under penaky of perJury /�
Date
�
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Construcdon Debrls Dispoaal Aft[davit
(requirad fa aU dertwlition aod ras�vation work)
In acwrdanea with the sucdt editioo otthe Saoe Buildia�Code.780 CMR satiau 111.5
Debris�aod dtis provisions of MQ.c 40,3 34�
Buildin�Pannit M is ia�uad wit�th�conditioa that the defuii raultin�flom
thi� worit ahall be disposed of ia a propely liceased waw dispo�al f�ci4ty a�deHnad by MCiL c
1 11.S i30/1.
'I�e debris will be transported by:
t< .s. .� t-- � �.rz.� r��S
�lo�m�d�� L ��
Tha dcbris wiU be disposed of in:
(aamr ot heiliry) ;
(mldem o!hcUiry) I
siYaawre o[ tieaat
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CITY OF SALEM
;�� , � PUBLIC PROPRERTY
DEPARTMENT
�sexcev nuccou
MAYOR 120 WASHQVGTON STREET�$ALEM,MASSACHUSETTS 01970
1'EL•978-7459595 �F,vt:97&7449846
Workers' Compensadon Insurance Affidavit: Builders/Contractors/Electricisns/Plnmbers
Apalicant Informstion Plesse Print Leeiblv
N3[[1¢ (Husiness/Organizauon/Individual): Zm �;�,zz- 1 , C-'� sTrt.f L
Address:_ 3 �7 �a.�.d. �.zzE,i„� �T--
Ciry/State/Zip: �o��:�. ti�1 m o c 9 7� Phone #: 9 � g 5 � <l � 6 '7 `i
Are you an employer?Check the appropriste bo:: Type of proJect(required):
1.0 I am a employer with 4. 0 I arn a general coatractor and I
employees(full aad/or part-time),• have hired the sub-contractors 6• ❑New conshucdon
2.�1 am a sole proprietor or partner. listed on the aaached sheet = �• ��m��g
ship and have no employees 1'hese sub-coatracwrs have 8. �Demoli�on
worlcing for me in any capacity. workers' comp. ins�uance. 9. �Huilding add{tion
[No workers' comp. insurance 5. ❑ We aze a cocporadon and its
required.J officers have exercised their 10.�]Electrical repairs or addiHons
3.� I am a homeow¢er doing all work right of exempdoa per MGL 11.0 Plumbing repairs or addidons
myseif. [No workers' comp. c. 152,§1(4),and we have no �2,0 Roofrepaus
insurance required.]f employeea. [No workers'
comp. insurance reyuired.j 13.0 Other
'A�Y%PP���cAeclu box pl mwt alao fill out the eection below ehow�ns lheir worken'eomprnaaHon pelicy infomutiea
�Hammwnm wM submit�hia�fTidavit indicating�hey are doing all wmk aod thm hiro outaide contncWn muet submil�mw ef7id�vit indiatinQ such
=Canhactan tMat cheek thi�box muet attached ao addidomi sheet aMwing the nama of tha sub-contracton and their worken'comp.poliq iafortmtloo.
/am an earployer that Lr providing workers'compensation insuronee jor my emp[oyeex Below is the polley and Job site
injormntion,
Insurance Company Name:_ l�] . s'�.
Palicy#or Self-ins.Lic.#: Expiration Date:
__ Job Site Address: '3 � ��� 24.�,. i ��-- City/State/Zip: Sm� r,.�,'� �
o [vi �za
— Attac6 a copy a(the worken'compensaHon poticy declsraHan page(showing the policy number and ezplraHon date}
Failure to secure coverdge as required under Section 25A of MGL c. 152 can lead to the imposidon of criminal penaltiea of a
fine up to S I,S00.00 and/or one-year imprisonment,as welt as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded w the Office of
Investigations of the DIA for insureoce coverage verification.
� aa nereoy cem�n��ns qnd pena(\l�rr,-u.fyr�Jury that t6e rnjormaNnn qovided above Is true and conect
Si�nature: `\\ ) Date: ►n / � � ! p �
Phone#: `) 7 � - 5 9 4 - 5 6 � ot
OJJlcid use only. Do not writt in thr.r areq to be campleted by city oi town oJJ7ciaL
City or Towo: PermitlLicenae#
Issuing Aut6ority(clrcle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Ptumbing Inspector
6.Ot6er
Contact Persoo• Phone#•
Information and Instructions
Massachusens General Laws chapter 152 requires all employecs to provide workers' compensadon for�o�e���Plo�'s.
p��i�this staNte,aa eroployee is defined as"...every pecson in che service of another�ndar aay
express or implied,oral or writtea."
An employo is defined as"an indrvidual,partnarsh�P.associadon,cotpomdon or other legal entitY,ar�nY hvo or moro
of the foregoing engagad in a joiat encerprisc,and inc►udw6 the legal rep�ntatives of a deceased employer,or the
receivet or t[ustee of an t�d�`nd�.p�0�p'���aon or other 1ega1 enaty,employing employees. However the
owner of a dwelling house havinB na�m°re than�apazRnents and who msides theroin,or the occupsnt of the
dwelling house of another who employs persons to do mazncen�°ce,constcucdoa or repsir work on such dweUing house
or on the grounds or building appurtanant thereto shall not because of such employment be deemed to be an employer."
MGL chapur 152,§25C(6)also statea thae"every state or local dcensin$agency s6sll wit6hold the issuance or
renewal of t ticenu or permit to operate a businesa or to construct buildinge in t6e commonwealth for any
applicant who has not produced acceptable evldence of complisnce witl►the insurance coverago required."
pdditionally,MGL chapcer 152,§25C(7)states"Neither the commonwealt6 nor aay of its polidcal subdivisions shall
• enter into any contract for ttu perfonnance of public work until acaePtable evidence of compliance wit6 the in��*Arce I
requirements of this ct�apeer have been presenud to the conhacting authority.'
.
Appticanta
Please fill out the workers' compensation affidavit completely,by checking the baxes that apply to your situation end,if
necessary,supply sulacontractods)nam°�S�•add��s�es�a°d phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limiced Liability Pactnerships(LLP)with nu emPloyees othcc thau the
members ar parmers,aze not required w cacry workera' compensation insurance. If an LLC or LLP doea have
employees,a policy is requirod• Bo advised that this affidavit maY be gubmitted to the Department of Indusaial
Accidents for confumadon of insucance coverage. Also be sure to slgn and date the sifidaviL 'The affidan��°�d
be retumed to the city or town that the applica stions eeazdin the lawe or if you are r quired to obtain a wo kers t ef
Industrial Accidents. Should you have any que B B
compensaaon policy,pleasa call the DeparCment a�the number listed below. Self-insurod companies should enter thair
��'• +�nce license number on the appropriate line
City or Town Offlcials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the botcom
of the affidavit for you to fill out in the event the Office of Investigarions has to contact you regazding the applicant
Please be sure to fill in the pe:midlicense number which will be�eeaz needeonly submi one affida vc ind�cating current
that must submit multiple permidlicense applicationa in anY 8 Y
policy informauoa��f necessar�')�d°°�"Job Site Address"the applicaat should write"all locations in (city or
io�);' p copy of the affidayit that has been officially stamped 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 or licenses. A new af:.duvu must be fillec�out aach
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog ticense or permit W bura leaves etc.)said person�s NOT required to compleu this affidavit
The O�ce of Investigaaons would like to thank you in advance for your cooperation and should you have any quesaons,
please do not hesirate to Biva us a caU.
The Depactment's address,celaphone and fax numbec:
The eommonwealth of Massachusetts
DepaRment of Industrial Accidents
Office of Invesd�allons
600 Washingcon Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-OS �y�y�y,meS3.gOv/Q18
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light fixture _ � � �
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access hatch access hatch �
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KITGHEN � 'i
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EXISTING BATHRDOM GEILLING pL4N ` NEW BATHROOM GEILING P�_N__ � "`
SGALE: 1/2,�_�,_0„ . . ee��M
SGALE: 1/2"=1'-O" eNr�rr
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' 1 1/2" snk dran � ��R �Q BAT �
� water le�es I I I �
61/2" 5'-0 3I V2" 1'-1CJ' BEDR�M �
1 1/2" sa�k drain BATHROOM � ,
vent 40" h �water Ines uV��, TO BE REMGflELEq �
Exist siud wall �
� �9/2' 'V2 ('h'Pical) � �� �
11/2" - --- -- - -- -- .=1
verrt up � � � , new stud�wall DINING �-
V2 I I m � L i DEN �
1 1/2" shk drain �,� I I c � _ =
�water Ines ' I I +� ry }- New�bo sink v �
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I I � � � I �$ --- REMO�E WALLS
ii � ,;% j �� , 3 i i� o�t � THIRD FLOOR PLAN- UNIT 5 � NEw ���Au.s
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I New Toiet
4f�1 t � -- 1 1/2" tub drain � �I : I
��/ �� water Ines -- - -------- � II SC.N_E: V8" =1'-O
- "-toilet // 4" cast �� �� i
- — �/ vent II
1/2 w er // 1/ - � Move toilet �+
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Move 1/2' water ExisY stud wall
(tyPicaQ �
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EXISTING B?�THROOM__FLO?OR_PL4N NEW BATHROC�M FL,OOR PLAN �' �
SGALE: 1/2"=1'-O" . SGALE: 1/2"-1'-O" �� � �
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