34 WARREN ST - BUILDING INSPECTION DEPARTNIFINT
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APPLICATION FOR PLAN EXANIINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
_. .
1:\IPOK"PAN'1': :�Applicants must com Irte all items on this page
sai., INFORNIA'rION
Location Name 3ZI Mi AiQQ6N Sr Building
Property Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Humes R3_R4_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) Rl _
(check one) Assembly (Theaters) All _
New Building_ - Assembly (restaurants & clubs) A2r_A2ne_
Addition Assembly (churches) Al
Alteration Business B_
Repair/ Replacement _ Educational E
Demolition_ Factory(moderate hazard) F1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building Institutional (residential cure) 11 _
Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile M _
Storage Sl _Moderate Hazard
Storage S2_Lo\v I1:¢ard
0W'N9UtS111P INFORMATION(Please type or Print Clearly)
OWNER Name
Address
Telephone
Signature
DESCRIPTION OF WORK TO BE PERFORMED
5En1 n zn
Ofyv%04-� OeA2 5 °F
b:5'TI:\IA TA ) CONSTRUCTION cos"r _ 3.S^VC> 0 0
CoN'rNAC OR INFORMATION
Name I ,rr\ �-rCvJf 1D °A —so N�
Address V? Qo Y'm fl1J PWIE
Telephone '178^77L/ f$)8
Construction Supervisor's Lic # 1655-69
Home Improvement Contractor# 365�S�
:utcllrrl{Crn:NGINi?ER INFORNIA'rION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CONINIEN,rs
The undersigned applicant does hereby attest that all infornnation stated above is trite to the best of my knolvledge
under the penalties of perjury
Signed / '�'� (owner) (agent)
APPROVED BY :
DATE APPROVED: 1• OL-2
I
ev.Brad Gosselin
t!
NSAC Trustee
Commisioned Healer 978-774-1571
Fax:BGoss924090aol.00m www.flrstspiritualistsalem.orgj 7:
Rat Spiritualist Church NSAC
BGoss92409gaol.com
Salem Me.01970
Rev Elizabeth Gosselin NST
Certified Medlum
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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VI.\Ylta 12C VAW.%t-TCN Smairr R SALEK 1L%2Lw .af77J 019n
ThL 9711-7e3.9S" a FAX:9767e0.yWe
Workers' Compensation Insurance Affidavit: BuilderstContactors/Electrlclans/Piumben
.applicant Information Q�,� Please Print Leeibly
Name ttlaaincztlor=ani:atiwlnJwulunp: : l'T` ZE4W NLD
Address.• A-41C
City/St2WJZip: QN'** 1' rLS •"A of ga3 lahone N:
Are you as employer?Cbeek the appropriate boar Type riate bope of project(requ(rer):
1.go 1 am a employ"with_ J___ 4. ❑ 1 am a gtmcrai contractor and 1
employers(full and/or pa -time).• have hired the sub-cwu aractor 6. ❑new comgruetioo
rt
2.❑ 1 am a sole proprietor or partner- listed on the attached shoot ; 7. 0 Remedoling
ship and have no emphlycets Thor have a. ❑Demolition
wonting for taw in any capacity. workers'comp. insurance. 9. ❑ Building addition
(Ao workers'comp. insurance S. ❑ We are a corporation and its rcquirelL) offtcera have czerciaa 10.
!their ❑Electricsl repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
InyselL(no workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(N'o workers 13.❑Other
comp inwrance required.)
•.\ny+ppb"W dw dusita boa el tot o also fill ant am seeam 1KWw awariaa their wvakam'amtpes "M Pdhy iefurmWia&
'11utrwuwmn wbo submit"oflldwit indi adat;dwy am&*V all wwk sae this,hie aWaies eaammota meal submit a paw aflldavil iediaa na such.i
:Cu rwxim Ihm cask this box mum anadmil anaddidawl Am dwwoy On taatw grew Wb•Gatihpom sad chew twtkwa'txtM pelt i iatotmantta
l am on employer that Is providing workers'coatpensaden huarance for my employees, Below Is the policy and Job site
fa/ctraaot"
Insurance Company Nome:7C _.
Volicy a or SclGins.Lie.M: _ .- __.. Expiration Date: I 'a:—3 1— o$
Job Site Address: 3 (-4 City/sIaLcizip: �Lt;� t /alA,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w sucum coverage as required under Section 25A of%IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.50.00 and/or one-year imprisonment,as well as civil pcnaltics in the form of a STOP WORK ORDER and a fate
of up to$250.00 a day rg:linsi the violator. lie advised that a copy urthis statcmcnt may be furwarded to the Office of
Im•.augmtmts ul'thc DIA for wiurarce coveragu verification.
l do hereby certify under the pains acid penahks ajper/ary that the informaNten provided above is true and correct
Date. /off — P —Og
1Vk41 wse onlyt Do not write In thk area,to be completed by city or town o,0?clld
Cityor'rown: PurmiV1.IcesseN___- „ _
Issuing Aulhurily (circle one):
L Guard of llealih 2. Building Mpartuuat 3.City/fovea Clerk 4.Electrical Inspector S. Plumbing Inspector
G. Other
C,natact Person: _ Phone At:
Information and Instructions
Massachusetts Gcncral Laws chapter 152 requires all employers to provide workers' compensation for their employe-.
Pursuant to this Mande.an r10111106 is defined as""'every person in the service of another under any=U=of hire.
express or implied,oral or written."
.An ersptoyor is drdieed as"m individual,p+sinershiP assoenanots.corporation OF other legal entity,or any two or more
of the foregoing engaged in a)oat enterprise.and including the legal representatives of a deceased employer,or the
a&soeiation or other legal cotity.employing employees. However the
receiver a dwelling
m its having not
psreeershap. and who raid-therais.or this occupant of the
owner of a dwelling hot-having not more than three apsrtrneahh
dwelling house of another who employs persons to do maintenance.cdwatruetion or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
AtGL chapter 152.;25C(6)also states that"every state or legal lictnslag agmtey stall withheld the tasuas+a or
reasewal at<•Reran or permit to operat
e a bus(nun er to eoastruet buildings In the commoawealeh far my
spptlraat who herg net produced acceptable wfdeaee of comptlaues with the insurance coverage required."
Additionally.MGL chapter 152,$25C(7)star "Neither the conmmnwealth tier any of its political subdivisio-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 conmacur g authority."
Applicants
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and,if
necessary.supply sub-contntctol(s)name(&),address(es)and phone number(s)along with their certifcate(s)Of
insurance. Limited Liability Compaoies(LLQ or Limited Liability Partnerships(LLP)with no employees Otte than the
members or paMcrs,ace 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 retuned to the city or town that the application for the permit or license is being requested, not the Department of
tnJuuriul Accidents. Should you have any questions regarding the low 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
,elf•iruuraoce license number on the a line.
City or Town ORfclab
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
Please be sure to till in the permir/license number which will be used as a reference number. In addition,ad applicant
that must subunit multiple permitilicenae applications in any given year,need only submit one affidavit indicating current
Site Address"the applicant should write"all locations in (airy or
policy information(if necessary)and under"Job
town).-A copy of the affidavit 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 of licenses. A new affidavit must be tilled out each
year. Where a home owner or cidun is obtaining a license or permit riot related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I'hc Ot liar of lnvcstigatIuns would like to thank you in advance for your cooperation and should you have any questions,
pleaoe do not hesitate to give us a call.
The Dcparment's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Indusaial Accidents
Omoa of Igiwstlpttlew
600 Washington Strad
Boston, MA 02111
Tel. a 617-7274900 ext 406 or I-977-MASSAFE
Fax N 617-727-7749
,teviscd 5-26-05 www.mam.gov/dia
-
PUBLIC PROPERTY
DEP.1RTbIENT
ri..a�snr n.wr.v
N eras 130 WARWAG 1N b%MEZr•swu4 AWAAoust`rms 01970
APPLICATION FOR THE REPAIR. RFMyAn_0&CONSTRUCTION
DE.rIOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 31TE INFORMATION
Location Name: -�nQ5i'.Sp-le 'UAzL1s-T.e. C
Property ------ — ------- -- - - - - -- - - ------ - -
Property is located In a;Conservation Ares YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address:
Telephone:
&0 COMPLETE THIS SECTION FOR WORK IN E7(IST1plt3 BUILDINGS ONLY
Addition Existing
Renovation )(XX X Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
Construction or renovation
of existing building New
grief Description of Proposed Work:
--—-----Mail Permit to: --- - --
What is the current use of the Building?
Material of Building? H dwelling.how many units4----
Will the Building Conform.to Law? Asbestos?
Archited's Name
Address and Phone ( 1
MachanWa Name
Address and Photo
Construction Supervisors License 0 HIC Registration f
Estimated Cost of Projed S Permit Fee Calcuiatlon
Permit Fee S Estimated Cost X:7/51000 Residential
Estimated Cost X$11/:1000Commercial
An Additional $5.00 is added as an
Administrative chary@.
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 the above stated
specifications. Signed under penalty of Perjury
Date
N
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06
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District: McIntire
Address of Property- 34 Warren Street
Name of Record Owner: First Spiritualist Church
Description of Work Proposed:
Replacement of existing stairs in kind with additional of wood balustered handrail per sketch submitted, utilizing 2 x 2
balusters, 4 x 4 posts, pyramid post caps, standard Brosco handrail. Height of railing and length of handrail along stairs to
be per building code. Lattice below to be wood, of sturdy quality. Entire to be painted white. Option to use Trex for deck
and stair treads.
Dated: August 7, 2008 SALEM HISTORRIIIC�AL COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..Us•ta er �►tL
�1��•s lie W.%mVw.-0Kj7traT•LW%WAIL A.*AbLA
To.Wp4tl)M 970,7+6906
Construction Debris Disposslt Affidavit
(required for all demolition and tenovadon worst)
in=onlame with the sixdt edition GUN Sets Building Coda.7110 CNIR smdoo 111.S
oebr*and the provisions of M. GL.a 40,9 A
suildirls Freest 0 _ _ is issuad with do condidoo that the debris mrAdng Born
this work shall be disposed of in a properly licensed watts disposal ftility as defined by%1GL e
11.1.915OA.
The debris will be transported by:
i.t�, B�-u� Qr�a•�S
_. Inaiee of naul.d
fhedcbds will be disposed of in :
nt+rn.ut'fxttay)
..�6r