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1 DALTON PARKWAY - BUILDING JACKET I DALTON PARKWAY 1 ' STAP�s. The Commonwealth of Massachusetts 4, CITY OF Board of Building Regulations and Standgdss SALEM (� W Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,RenAke koiR a2: 39 IT One-or Two-Family Dwelling Tis 8eddba F+trr f) :We only Building Permit?]ember. A.pplied: I� )wilding Of{tcial(Print f3ame) Sigaanue Date I— SECTION li SITE YNFORMATION 1.1 Pro Address: 1.2 Assessors Map&Parcel Numbers Lla Is this an accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public 11 Private❑ Check if yes❑ �eSECTION 2 PROPER TYOWNERSHIPt 2.1 OJ Ems )ord: ©(UVrJO�I Name(Print) City,State, IP No.and Street Telephone Email Address N SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Altera ion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed World: SEC17ON 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item abor and Materials 1. Building Permit Fcei$ indicate how fee is determined: 1.Building :� ❑Standard City/Town Application Fee 2.Electrical $ U Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: _ 5.Mechanical (Fire $ Total All Fees:$ Suppression - ���� (Steck No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Fall 17 Outstanding BalanceiI ]hie: Mia I t� 9( 3a -11 zo SECTION S. CONSTRUCTION SERVICES f 5.1 Construction,SupervisorUcense(CSL) lU h ceA� (OA) )0-11 License Number 7 1 Expiration Date 7 Name of CSHolder ' List CSL Type(see below) b -Ctl/L47�ULv7 q' Description . No.and Street U Unrestricted(Buildings up to 35.000 on.ft. R Restricted]&2Family Dwelling City/fown,Stated M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) a S /t'V1-S&A./✓' C Registration Number Enpirauon ate HIC Coparry me or HIC Registrant Name No.and Street �"�— Email address r a� tL/\ §W--7Yf k 7�r Cl /To Sta a Z✓IP Tel hone SECTION tit WORKERS°'COMPENSATION INSURANCE AFFHIAVTT(1VLG.L G 152.§ 2SQ6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........)kl No...........❑ SECTION lac OWNER AUTHOWA TO RE COPAPIXTEA WHEN OWNER'S AGENT OR CONTRACTOR APPI�A.IMYOR VILIT PIING PERM 1,as Owner of the subject property,hereby authorize �/' ) �� /nn ).r to act on my behalf,in all matters relative to work authorized by this building permit application. Print Offer s Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained' s application is true and accurate to the best of my knowledge and understanding. Ck 1)A )G1/� �dJ �— Print Owner's or Authorized Agent's Name(Electronic Signature) Date 'NOTES; 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at mm milaLgav/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" } CK I LA -7-3 3' 4 The Commonwealth of Massachusetts . CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR CC��oo qq gQyisedMar 2011 Building Permit Application To Construct,Repair,Renom CffDetYiblha Lis t One-or Two-Family Dwelling Section I" i:Use . ® Buil"Pernit;hFumlier . .. Date APP 7/�a or iin ergl(PrintRam i Slaita® SECTION lb SITE*00RM47[f3N 1.1 Pro Address: 1.2 Assessors Map&Parcel Numbers I 1.la s this an accepted street?yes_ no_ Map Numb Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(fl) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone. — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es[3 SECITI011 PROPERTXpWNERS13IPt 2.1 Ovyinfr of Record: / 18l— Name int) City,State,ZIP - No.and Street Telephone Email Address SECTION 3.DESCRIPTION OF PROPOSED WORK](t beck all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 13 Alteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg.❑ 1 Number of Units 10ther ❑ Specify. Brief Description of Proposed World: SECTION 4:ESTI117ATED CONSTRUCTION COSTS Estimated Costs: official use Only Item (Labor and Materials 1.Building $ 1, Building Petnit Fee:$ Indicate hots fee is determined: q St�daztl Clty/fown.Application Fee 2.Electrical $ ❑Tonal Project Costs(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List. 5.Mechanical (Fire $ Total All Foes:$ Su ression �Y�/ , (5ieck No. Cheek Amount Cash Amount' 6.Total Project Cost: $ 3 LL/C/ ❑Paid in Folt ❑Outstanding Balance 1)ue: sECITON 5: CONSTRUCTION sERVICIV& 5.1 Construction Su ervisor License(CSL) � 7 (^3/�i ��✓\ License Number Date Nf CSL Holder List CSL Type(ace below) 6---- 2 nesse No.and Street - ' Unrestricted 'dm to 35000 w.R St ' Restricted 1&2 Famay Dwelling City/Town,State,ZIP M Masonry RC I Rwfing CoveringqExp �7 p WS Window and Si <-L- —�-��/�1 SF Solid Fuel Bor I Insulation Telephone Email address D Demo&tion 5.2 Registered Rome Improvement Contractor(HIC) ?� 10 7 ,S yck dC�Rogistration Nu HIC mpm Name or HI Registrant Name No.an t Email address Ci /town State ZIP Telephone SECTMN�:WORKERS'COMPENSATION IIM?RANCE APFHIAVIT @LG.L,c:152.4 25C(6)) Workers Compensation Insuwnce affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........O ACTMN int OAMft AI7TH6RWA TO At COMPLETED VAnN WNER'S AGENT ORL4 CTgR. Pt>R . : ING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORVM AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contain in this application is true and accurate to the best of my knowledge and understandin . I nir Print mer's or Authorize A t' ame(Electronic Signature) ate ,. NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at jMyMass. og vloca Information on the Construction Supervisor License can be found at www.rnass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Certificate Number: B-16-990 Permit Number: B-16-990 Commonwealth of Massachusetts City of Salem This is to Certify that the ..............................................................Single Family Building....................................................... located at Building Type 1 DALTON PARKWAY........................................................................ in the .....................................City of Salem ................................................. Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Single Family Home SEAN O'CONNOR This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ...............................NotAPPlic*k............................. unless sooner suspended or revoked. Expiration Date Issued On: Thursday, April 27, 2017 Certificate Number: B-16-990 Permit Number: B-16-990 Commonwealth of Massachusetts City of Salem This is to Certify that the .......................... ..............................Single Family Building..................................................... located at Building Type ...................................................................... I DALTONPARKWAY_ ........................................................................ in the ...................................._City,of Salem Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Single Family Home SEAN O'CONNOR This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ...............................Not Applicable unless sooner suspended or revoked. E)piration Date Issued On: Thursday, April 27, 2017 Commonwealth of Massachusetts p, , Citv of Sale' m .. . .- 120 W ashln tort St,3rd Floor Salem,MA 01970(978)745-9595 x5641 �. Return card to Building Division for Certificate of Occupancy' - R Permit o. 6.16.990 p ERMIT TO BUIL D FEEE PAPAID:D: $238.00 �. DATE ISSUED: 9/12/2016 s j e This certifies that OCONNOR SEAN OCONNOR ROBERTA t. ' , D I has permission to erect, alter, or demolish_building~;,;,_1,DALTON.PARKWAY Map/Lot: 2501540 , as follows: Repair/Replace REP-LACE KITCHEN CABINETS; REMODEL THREE (3) BATHS& MASTER BEDROOM is Contractor Name: SEAN O'CONNOR f � I DBA:. PRESERVE SERVICES:r j Contractor License No: 093403 b i1 f I 9/12/2016 BuildirldIMM,.i9c7 7 Date `< This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six itlonths after issuance.The Building Official may grant one or more extensions not to exceed six months eachupon written request. r Ali work authorized by this permit shall conform to the approved application and the approved-construction,documents for wit titis permit has been granted. All construction,alterations and changes of use of any'ilding and structures shall be in compliancewith the tical zoning bylaws and codes. -, This permit shall be displayed in a.location clearly e -applicable signatures by the and shall be maintained open for public inspection for the entre duration of the work until the completion of the same. Peady visible from access street or road !J f! ., The Certificate of Occupancywill not be hssued.until all 9 Building and Fire Officials are provided on this permit.- - >';;: 'Persons conlractl (asset ` f HIC#: 123553 ng with unregistered convectors do not have access to the guaranty fund' forth InMGUc.142A). Restrictions: f� � � Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. 0 r Commonwealth of Massachusetts Citv Of Salem 120 Washington S4 3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for certificate of OccupancK F - Structure _ CITY OF SALEM BUILDING PERMIT Excavation PERMIT TO BE POSTEDQIN THE WINDOW t i Footing - INSPECTION RECORD! - , APs 4g r Foundation _ Framing Mechanical - Insulation [Y I a l� INSPECTION: j BY DATE Ch(mney/Smoke bfiember Final r✓ UA G / l Plumbing/Gas �alQ / G 0 `: Rough:Plumbin - Rough:G _ y. - r. w. •. Final - a Electrical LV Service 'r Rough/ Final Fire DelivaWment � Y,r' � a rMnal nary _ t! r .- Health Department r nary �. db - - Final ' e . i x J: n Commonwealth of Massachusetts A City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 ° Return card to Building Division for Certificate of Occupancy -- Permit No. B-16-990 PERMIT TO BUILD FEE PAID: $238.00 DATE ISSUED: 9/12/2016 This certifies that OCONNOR SEAN OCONNOR ROBERTA has permission to erect, alter, or demolish a building 1 DALTON PARKWAY Map/Lot: 250154-0 as follows: Repair/Replace REPLACE KITCHEN CABINETS; REMODEL THREE (3) BATHS & MASTER BEDROOM Contractor Name: SEAN O'CONNOR DBA: PRESERVE SERVICES Contractor License No: 093403 9/12/2016 Buildirkl(35fif I�f 7 Date This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Oficial may grant one or more extensions not to exceed six months each upon written request. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. HIC#: 123553 "Persons contracting with unregistered contractors do not have access to the guaranty fund'(asset forth in MGL c.142A). Restrictions: Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. Y Commonwealth of Massachusetts ! i City of Salem n 120 W ashington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 � Return card to Building Division for Certificate of Occupancy Structure CITY OF SALEM BUILDING PERMIT ° PERMIT TO BE POSTEDaIN THE WINDOW Excavation "•� Footing INSPECTION RECORD Foundation Framing ,x)( Mechanical F Insulation , INSPECTION: BY DATE 0Y Chimney/Smoke Chamber 1 Final O G Awl Plumbing/GaS r Rough: Plumbinc7.�rJ Rough:Ga iill7�vv Final t Electrical Service t Rough% // /Z Final !E j'-7Ca Fire Defiartment jW Preliminary Final Pr(:'i.� Health Department eliminary ri Final Commonwealth,of Massachusetts .. { r City of Salem , 120 W ashington St,3rd Floor Salem,MA 01970(978)745-9595x5641 .. - "Return card to Building Division for Certificate of Occupancy'' FEE Permit $238 .a's- 90 PERMIT TO BUILD i DATE ISSUED: 19/ This certifies that 'OCONNOR SEAN OCONNOR ROBERTA has permission to erect, alter, or demolisha p buildingl,DALTON_2ARKWAY Map/Lot: 2501540 r,> as follMvs: Re 'air/Re lace REPLACE KITCHEN CABINETS; REMODEL THREE (3) BATHS & MASTER p BEDROOM Contractor Name: SEAN O'CONNOR .----,--..--.—._----_..,, DBA: ` PRESERVE SERVICES ` t Contractor License No: 093403 { I ft 9/12/2016 j . Buildi A IOf 0� ADate s x +� This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within n'ths after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. ' All work authorized by this permit shall confoml to the approved applicationand the approved constructiondocuments for wh is permit has been granted. - - I I I All construction,alterations and changes of use of any building and structures shall.be in compliance with the local zoning by-laws and:codes. I . 4 ., This permit shall.be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the .. I work until the completion of the same., t !)7 fff s The Certificate of Occupancy will not be issued until all.applicable signatures by the Building and Fire Officials are provided on this permit. , H IC#: 123553 - � _ "Persons contracting with unregistered contractors do not have access to the guaranty fund'(asset forth in MGL 042A).. t, Restrictions: r- Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. 9 + y Commonwealth of Massachusetts 'r City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 , - Return card to Building Division for Certificate of Occupancy " Structure CITY OF SALEM BUILDING ;PERMIT Exon PERMIT TO BE POSTEDoIN THE WINDOW Footing = INSPECTION RECORD; E of Foundation Framing •X>( 10111��� � - " • Mechanical Insulation S �(� INSPECTION; BY DATE Chimney/Smoke Chamber Final Olk UP YIJL %A Plumbing/Gas' C p . Rough:Plumbin I f t� - ! •, ,..- t . Rough:G .t .9 Final _ { t r ElectricalVj Service Rough/ �r✓i Ce e .Y s Final I Fire De artment } Preliminary Final - n Health Department �r x . Preliminary Final Mt �f Certificate Number: B-16.990 Permit Number: B-16-990 Commonwealth of Massachusetts City of Salem This is to Certify that theSingle Family Building located at Building Type ...........................................................................DALTON PARKWA.Y........................-.............................................. in the .....................................City of Salem ................................................. Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Single Family Home SEAN O'CONNOR This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ...............................Not A_ppticabte unless sooner suspended or revoked. E)piration Date Issued On: Thursday, April 27, 2017 .....-.�. -x..�'M'+"^T.^.n.--n-...dV+..^'r-wa..'r^,-n�.«i-'F.+.w.'^v:,J^^"trld.+.+.sn.s-y"r^.,,`..-^^.-"�"..yr.\•rv..yT.,�,-.- .r'-�•. �Ltm .Y"..+iw•+.fes ^^Pr'. v��cownr FIELD COPY y° BUILDING 0 CITY OF SALEM +1 �r SALEM, MASSACHUSETTS 01970 PERMIT '{i VALIDATION DATE July 20 Is 94 PERMIT No. 287-94 APPLICANT Fred Freeman ADDRESS lb Hancock-19—t . Salem, Mass. 050852 IYO.1 If IA[[TI ICOY\Yq ,I(EMU Roof Dwelling MUMBER or 1 PERM-T iO 1_1 STORY OWELLINQ UNITS - II.1[ O�;IYIROV(N[Mll YO._ IIYOIO{IO V{II AT ILOCAT-OYI 1 Dalton Parkway Ward 3 ZONING ONIN�T $2 IYO.I ISIIE[TI tom__ SET WEEM AND IMO{I NA[{II I<ADR {r q[\I LOT SUBDIVISION LOT BLOCK SIZE - BUILDING IS.?0 BE FT. WIDE Or FT. LONG BY FT. IN MEIGNT AND SMALL CONFORM IN CONSTRUCTION - TO TVP[ USE GROUP BASEMENT WALLS OR FOUNDATION ITTPtI REMARKS: Permit to install new roof O LUME I ESTIMATED COSTS 5,000 i[MI7 S 35.00 .: ]WNER • I ' 17..DREIS 1 Dalton Parkway Salem, Mass. - John .T. J 3;apn INSPECTOR OFrBUILDINGS fib-L Z- noa»r�wi frrrw36 on• swn3la4r3-- ■siroorr axon NAVO ii Omons N011:)3d$Nl No. S City of Salem Ward a r APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete ' all items in sections:1, 11, III, IV, and IX. 1. AT(LOCATION) 1 yfcl.TbN -f>[Q(L..�..q ZONING STINKY LOCATION (NO.) ( 1I `' OF BETWEEN iJF �- AND puW7 (CROSS STREET) (CROSS STREET) BUILDING LOT —yJ w SUBDIVISION LOT I6 BLOCK SIZE $(�.(�` II. TYPE AND COST OF BUILDING -All applicants complete Parts A -D A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION'USE MOST RECENT USE 1 ❑ New building Residential Nonresidential 2 M Addition(It residential,enter number of new 12 One family 18 ❑ Amusement,recreational housing units added,if any,in part D, 13) 19 ❑ Chruch,other religious 13 ❑ Two or more family-Enter number 3 ❑ Alteration(See 2 above) of units .................................................... 20 ❑ Industrial 21 ❑ Parking garage 4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- Enter number of units ........................... 22 ❑ Service station,repair garage 5 ❑ Wrecking(If multifamily residential,enter number 23 ❑ Hospital,institutional of units in building in Part D,13) 15 ❑ Garage 24 ❑ Office,bank,professional 6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility 7 ❑ Foundation only 26 ❑ School,library,other educational 17 ❑ Other-Specify 27 ❑ Stores,mercantile B.OWffERSHIP 28 ❑ Tanks,towers e Private(individual,corporation,nonprofit 29 ❑ Other-Specify institution,etc.) 9 ❑ Public(Federal,State,or local government - C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant, a machine shop,laundry building at hospital,elementary school,secondary school,college, �p parochial school,parking garage for department store,rental office building,office building 10. Cost of improvement ......................................................... $ <�• at industrial plant.If use of existing building is being changed,enter proposed use. To be installed but not included in the above cost a. Electrical........................................................................... b. Plumbing.......................................................................... c. Heating,air conditioning............................................. d. Other(elevator,etc.)..................................................... ` 11. TOTAL COST OF IMPROVEMENT $ Z0 III. 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.'PRI IN-CtIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL 1. TYPE OF MECHANICAL 30 Masonry(wall bearing) 35 Gas 40 Public or private company Will there be central air 31 Wood frame 36 Oil 41 ❑ Private(septic tank,etc.) conditioning? �-�Tf1 32 ❑ Structural steel 37 ❑ Electricity 44 El 45 I No 33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an elevator? 34 ❑ Other-Specify 39 ❑ Other-Specify 42 1�Public or private company 46 ❑ Yes 47 No r} 43 ❑ Private(well,cistern) ( J.DIMENSIONS t M. DEMOLITION OF STRUCTURES: 48. Number of stones ........................................................... 49. Total squareed of of exterior Noor area, all floors,based Has Approval from Historical Commission been received dimensions .........................................W.iF........ for any structure over fifty(50)years? Yes_ No_ 50. Total land area,sq.It................$679............._.. Dig Safe Number K.NUMBER OF OFF-STREET PARKING SPACES Pest Control: 51. Enclosed........Q................................................................ 52. Outdoors ......... HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? Yes No L RESIDENTIAL BUILDINGS ONLY Water: 53. Enclosed...............................................__.._....._....:........... Electric: Gas: Full............ ......................... Sewer: 54. Number of bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED Partial.----......................... BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic District? Yes_ No"� (If yes, please enclose documentation from Hist. Com.) Conservation Area? Yes_ NoI/ (If yes, please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No_ Is property located in the S.R.A.district? Yes_ No Comply with Zoning? Yes`/ No (If no,enclose Board of Appeal decision) Is lot grandfathered? Yes_ No (If yes, submit documentatioMf no,submit Board of Appeal decision) If new construction, has the proper Routing Slip been enclosed? Yes_ No Is Architectural Access Board approval required? Yes_ No✓ (If yes,submit documentation) Massachusetts State Contractor License# O45975 Salem License # 119 } Home Improvement Contractor# 16 Z 4b3 Homeowners Exempt form (if applicable) Yes_ No_ CONSTRUCTION TO BE COMMENCED WITHIN SIX(6) MONTHS OF ISSUANCE OF BUILDING PERMIT CONSTRUCTION IS TO BE COMPLETED BY: •• 11 -- esr If an extension is necessary,please submit NOS. ZD t in writing to the Inspector of Buildings. V. IDENTIFICATION - To be completed by all applicants Name Mailing address-Number,street,city,and state rZIPde Tel.No. a 7�p QqOwner orLessee 2. t:Rf T 12 3•ACYhoa Sf- i. T L4 I ciz-7Contractor 'sNo. 9 3. Architect or Engineer I hereby Certify that the proposed work is authorized by the owner of record and that I have been authorized by The owner to make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction. Signature of a licant Address Application date 3 1 Z X57. 'lziEJIERfV -AMt•O tj19' " DO NOT WRITE BELOW THIS LINE VI. VALIDATION Building FOR DEPARTMENT USE ONLY Permit number Building Use Group Permit issued 19 Fire Grading Building e-7 y � Permit Fee $ /—f/± Live Loading Certificate of Occupancy $ ApprovedOccupancy Load Drain Tile $ Plan Review Fee $ ` TI E NOTES AND Data-(For department use) PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by: Completed by: r y VI ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN -For Applicant Use O N v1 i NOTE.' ASSESSORS' MAP 2 5 , LOT l5y THIS PLAN IS NOT TO BE USED FOR TITLE INSURANCE PURPOSES NOR FOR RECONSTRUCTION OF PROPERTY LINES. ZONING.' R E 51 D EN7 A L. 2 REFERENCES.• DEED BOOK /ZZ Lf PAGE Zl5 m� it e a 4� EXi5TIN6 ? BLDG AREA/AREA = j.5 ry. e 0 C F E:xISTING 9' PROPOSED Lor 2370 6LDG AREA AREA Q' oI LOT AREA 72b5,t 5.F,, o Z s (COMPMTED) S y x6 79,'-s.-. �� o �jo s m �a r°aj I DDNc 7o ed '� O ,C �� ',r. --- SEEPS RCNoueD I B.H. LP5 0 C �� p9� C 'to; y � EXISTING ° �9y ? V2. STY , 7t WD. DWG . CONC. qq STEPS A� ZD DALTON PARKWAY I CERTIFY TO THE 54C6M Ou'L-PIA<i iAu•PEcmr— PLOT PLAN THAT THE Dw�u iAtG SHOWN HEREON /.S LOCATED ON THE GROUND AS SHOWN. OF LAND IN SALEM, MA55. q; PREPARED FOR - 4 j4ME5 .DA y� L" -7 bYZ / SCALE.' 1 " = ZD J4NUA12 r 31 1994 DATE ROF SIONALf•LAW-SURV YOR Zo /o o Zo ao qgA HANCOCK SURVEY ASSOCIATES, INC. 235 NEWBURY STREET-DANVERS, MA 01.923 CHECKED 8Y.' No. City of Salem _ Ward cOr+dt� [X 5 0�S 4C4eNE APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete all item in sections:1, 11, 111, IV, and IX 1� ,I/I ZONING 1. AT(LOCATION) 1 l DISTRICT LOCATION ("o.) yy 1I (STREET) &I OF BETWEEN 0,4 AND BUILDING (CROSS STREET) (CROSS LOTET) SUBDIVISION "- LOT BLOCK SIZE II. TYPE AND COST OF BUILDING -All applicants complete Parts A-D A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION"USE MOST RECENT USE 1 ❑ New building Residen Nonresidential 2 E] Addition(It residential,enter number of new 12 One family 18 ❑ Amusement,recreational ft ,units added,it any,in part D,13) 19 ❑ Chruch,other religious amu( 13 ❑ Two or more family-Enter number 3 All (See 2 above) of units .................................................... 20 ❑ Industrial 21 El Parking garage 4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- Enter number o!units ........................... 22 ❑ Service station,repair garage 5 E] Wracking(ll multifamily residential,enter number 23 ❑ Hospital,institutional of units in building in Part D, 13) 15 ❑ Garage 24 ❑ Office,bank,professional 6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility 7 ❑ Foundation only 26 ❑ School,library,other educational 17 ❑ Other-Specify 27 ❑ Stares,mercantile B.OWNERSHIP 28 ❑ Tanks,towers 8 ❑ Private(individual,Corporation,nonprofit 29 ❑ Other-Specify institution,eta) 9 ❑ Public(Federal,State,or local government C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant, did., ] machine shop,laundry building at hospital,elementary school,secondary school,college, . .._V_.� parochial school,parking garage for department store,rental office building,office building 10. Cost of improvement ....V.JJ(//( ,f ", ""'--"""'-.-""" $ at industrial plant.If use of existing building is being changed,enter proposed use. To be installed but not incluqed in the above cost a Electrical.......................�./..../.. ............... .... .......... ............ b. Plumbing.....................I._.,.._........................................... c. Heating,air conditioning.... d. Other(elevator,etc.)..................................................... // 11. TOTAL COST OF IMPROVEMENT $ `v 111. 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. PRINCIPAL TYPE OF HEATING FUEL G. TYPE fdF SEWAGE DISPOSAL I. TYPE OF MECHANICAL 30 asonry(wall bearing) 35 ❑ as 40 Ir,YJ� Public or private company Will there be central air 31 LWood frame 36 Oil 41 ❑ Private(septic tank,etc.) ^ditioning? 32 ❑ Structural steel 37 ❑ Electricity 44 ❑ Yes 45 MNNO TYPE1O WATER SUPPLY 33 ❑ Reinforced concrete 38 ❑ Coal H. � Will there by an elevator? 34 ❑ Other-Specity 39 ❑ Other-Specify 42 Public or private company 46E] Yes 47 No 43 ❑ Private(well,cistern) J.DIMENSIONS M. DEMOLITION OF STRUCTURES: 48. Number of stories ................... ...................................... 49. Total square feet of floor area all floors,re fa Has Approval from Historical Commission been received ee on exterior dlmensions ...................... for any structure over fifty(50)years? Yes_ No 50. Taal land area,sq.ft................................... Dig Safe Number K.NUMBER OF OFF-STREET PARKING SPACES Pest Control: 51. Enclosed ................................... ........_ . HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? 52. outdoors ................. Yes No L RESIDENTIAL BUILDINGS ONLY Water: 53..Enclosed............ .............................................. Electric: Gas: 54. Number of Full....................-..................... Sewer: . bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED Partial ........... I I BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic District? Yes_ NO (If yes, please enclose documentation from Hist. Com.) Conservation Area? Yes_ No (If yes, please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No Is property located in the S.R.A. istrict? Yes_ No Comply with Zoning? Yes_ No_ (If no,enclose Board of Appeal decision) Is lot grandfathered? Yes No (If yes,submit documentation/if no,submit Board of Appeal decision) If new construction, has the proper Routing Slip been enclosed? Yes_ No Is Architectural Access Board approval required? Yes_ No_ (If yes,submit documentation) Massachusetts State Contractor License # 6 Salem License# Home Improvement Contractor# Homeowners Exempt form (if applicable) Yes_ No_ CONSTRUCTION TO BE COMMENCED WITHIN SIX (6)MONTHS OF ISSUANCE OF BUILDING PERMIT CONSTRUCTION IS TO BE COMPLETED BY: Q If an extension is necessary, please submit in writing to the Inspector of Buildings. V. IDENTIFICATION - To be completed by all applicants Name Mailing address-Number,street,city,and state ZIP Code Tel,No. Owner or / a !'(/ / ) dl? l Jy^ 7 a Lessee 2. Contractor I �U � License No. {J 3. Architect or Engineer I hereby certify that the proposed work is uthorized by the owner of record and that I have been authorized by the owner to make this application as his authorized a n and we or to all applicable laws of this jurisdiction. Signature of applicantAddress Applican / Lia' '. DO NOT WRITE BELOW THIS LINE VI. VALIDATION " Building _ [J FOR DEPARTMENT USE ONLY Permit number j Building Use Group Permit issued t 9--L-F Fire Grading Building ��� \ Permit Fee $ (U Live Loading Certificate of OccupancyApproved by: $ Occupancy Load Drain Tile $ —�_ 0 Plan Review Fee $ /o ` TITCE NOTES AND Data • (For department use) tf1-6 o �-- l bQ a� v0►-, ¢ v hd_ lv PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by: Completed by: VI ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN •For Applicant Use O N DALTON RNC�C�T��1 7-1 - 42'' 7)ooZ:_ - - 32r� oorQ _ A y - �E10W�R r - - _. _.. a�titiatr7�ly"Anhltly -- - ! - - - - - S ------------- N _. ... ...eu 4. - _. .' _.TYF 1'D LOC, 7 i r r Gi VICFS ARE S=Jfl[ T M-r _:_vx F6RCC'(`C£lc�nirLi_ ._- — . INC - -- ---- 1 - ! ---1 - -- - + -- .__ ___. _ 1Q—jam_ _ _ tL IV COMMONWEALTH OF MASSACHUSETTS n •� 6 �c DEFAR.MENT OF INDUSTRIAL ACCIDENTS ' 600 WASHINGTON STREET fames: Camooeu BOSTON, MASSACHUSE'T'TS 02111 n^ss7one WORKERS, COMPENSATION INSURANCE AFFIDAVIT �G� ,o1wn li, Thr f I icensmi purnirme! with a principal place of business/residence at: --� (City/5umizip) do hereby certify, under the pains and penalties of perjury, that: � ) I am an employer providing the following workers' compensation coverage for my empiovees working on this lob. 61 Insurance Co any Policy Number il am a sole proprietor and have no one working for me. [ J I am a sole proprietor, general contactor or homeowner (circle one) and have hired the contactors listed below who have the following workers' co sensation insurance policies: elan ,0. Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number [) I am a homeowner performing all the work myself. NOTE: Please be aware that while bomeownen who employ persons to do maintenance,construction or repair work on a dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto am not generally considered to be employers under the Worken' Comvensation Act(GL C. 152.sect. 1(5)), application by a bomeoweer for a license or permit may evidence the legal tutus of an employer under the Workers' Compensation Act I understand that a coot'of this statement will be forwarded to the Dcsartmerst of Industrial Accidents' Office of Insurance for coverage �cnneation and that faiium to secure coverage as required under Section 25A of MGL 152 cast lead to the imposition of criminal penalties consisting of a fine of up to $1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Slop'Work Order and a Fine of 5100.00 a day against me. Signed this �l� day of rU2r 19 �- Licenseei l ermirree licensor/Permittor SaZern F4,te Depaatmejm_� F-ZAe Rtevent,4on. Suotoff t, APPOINTMENT FOR FINAL 48 La4ayexte Street INSPECTION MUST BE Satem, ma 01970 MADE AT LEAST ONE WEEK :1 (508) 745-7777 AHEAD-_,,,,,,,,__----" FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT In accordance wZVL the pjtov.L44orj,6 o4 the Ma44achu,6ett.6 State 8utZdZn 1 9 Code and the Satem F-4-te Code, aPPt-4cxLt.Zon .w hereby made 40-t app-tovat o4 ptan4 and the Z44uance 04 0- CeAtt4-4cate o4 app tovaZ 40-t a buZZdZng pen nit by the Satem F-Zte Department. (Re4. Section 113. 3, M"-6. State 8,edg. Code,) Job Location: lot, Owne,%/Ocr-uPant: 4�IAL' Ou EZect� caZ ContAar-to-%: F4�%a Suppt".64,on Cont4ar-to.%: S.Zgnatu,te 0b -10 Appt.Lcant: Phone Appt-e,6Lcant4 Add,t .6 o: uTown: 0.'L 0h Ap ilk App,tovat date: 1�tN APPOTMENT FOR FINAL 9'v INSPECTION MUST BE MADE AT LEAST ONE WEEK a,ft Ce,tt,444c04 aPP-tovaZ 46 heAeby .94xurted, on app-tovA ejAD Tl�---ujE_6_u_ffm_tttat 016 P40jer-t detmtZ4, by the Satem F.4:i%e Depa4tment. AZZ ptarL4 ate app.%oved -6otAZy 4ot tdent444x�- on 04 type and ZO* cat"n 04 44-te P-totect-ton dev-4ce.6 and equtpment. AtZ Pt4r?,6 Zte .6ubirec-t to app-tovat 04 any othe,% authoAZty hay.Zn_q ju4Z-6dtctZon. :Upon comptetton, the appZ4cant on Zn4tattet(4) aha ZZ 4eque,6t an -Z"pemt4on and/on tz4t o4 the 6_'E-te p-toteatzon devtce,6 and equtpment. FOR ADDITIONAL REQUIREMENTS, SEE REVERSE SIDE *m ) LJ New mon4tuLctton. P-%OPe-%tY to=tton ha,6 no r-ompZianr-e with. the F-tovt4,4orw o4 ChaPt" 148, Seztzon' 26 C/E, M.G.L. , 4zZattve to the 4jt6tzLtatZon o4 apptoved 44ne ataitm de-vZr-e.6. The own" 04 th'i-6 P-%0Pe4tY 44 -omqut4ed -to obta-in mompt-Lance a.6 a condtt.Lon oj obta4n,4n9 a guttdtng Permit. _P-t0Pe,%tY -Zocat-Lon 46 .in QOMPtiance w4th the Ptov46tonz a6 ChaPte& 148, Section 26 C/E, M.G. L. Fxpt4a.tton date: CJ4 e 0 Fee due: under 7, 500 Sq. Ft. $10. 00 7 . 500 Sc. F,t to.... FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT In compliance with the provision of Section 113.5 of the Massachusetts State Building Code, and under guidelines agreed upon by the Salem Bldg. Inspector and the Salem Fire Chief, the applicant for a building permit shall obtain the Certificate of Approval (see reverse side) and stamped plan approval from the Salem Fire Prevention Bureau. Said application and approval is required before a building permit may be ` issued. The Massachusetts State Building Code requires compliance approval of the Sales Fire Department, withreference to provisions of Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts General Laws, and 527 Code of Massachusetts Regulations. The applicant shall submit this application with three (3) sets of plans, drawn in sufficient clarity, to obtain stamped approval of the Salem Fire Department. This applies for all new construction, substantial alterations, change of use and/or occupancy, and any other approvals required by the Massachusetts General Laws, and the Sales Fire Code. Exception: Plans will not be required for structural work when the a w proposed work to be performed under'the building permit will : .'.Z m w not, in the opinion of the Building Inspector, require aQ: z plan to show the nature and character of. the work to be o performed. Z g co ` `- >wgw i Notice: Plans are normally required for fire 4suppression systems, z fire alarm systems, tank installations, and Fire Code0 Kr requirements. o w `" o CoQ y w t.4- ler �.¢Z �' a ; Under the provisions of Article 22 of the Massachusetts State Building Code, certain proposed projects may not require submission of plans or complete compliance with new construction requirements 'Jn these cases, provisions of Article 22, Appendix. T, and Tables applicable shall apply. This section shall not, however, supersede„the a11A% provisions outlined in the Salem Fire Prevention Regulations, Chapter 148, MGL, or 527 Code of Massachusetts Regulations. •,All permits for r.;E fire code use and/or occupancy shall apply for the entire structure; fire alarm and/or smoke detector installation shall apply to the entire structure based upon current requirements as per Laws and/or Codes, but the existing structure may comply with regulations applicable for existing structures. . Notice: Sub-contractors may also be required to file individual .applications for a Fire Department Certificate of Approval for the area of their work. Such sub-contractors shall file an Application to Install with the Fire prevention Bureau prior to commencing any work for those areas applicable. Form 81% (10/90) FPPOINTMENT FOR FINAL' INSPECTION MUST BE MADE AT LEAST ONE WEEK A.HEAD..,...... ,.,- •' -` v" ` , ' ,r .,.cw ,1-.• ', .: riS"Pf c^Ali?Tkf..'cz t•rr<♦1-H.sS•_ ,F,.. . `t}: '•2 11i"' °"rt,�2,tS`< �..fit i +:PyA fy/f� 1 i(�✓ ' bbNt • � � Y a, T� , �- .. " '. _ �..5 �. Z :C1, � S- -PRM Tf .. .:. - `• ,: �,,,� . -•.. . .._� �.♦ yam- _+.._. �..:- -.-- t:...- `._.,,,n. �� a"F-- , ".�i•cd+.. +Lw+:a'r ��: t �!'S r :r ��•••-��_•,r �., : �✓ Y ry •., ( \ ,' w .••, .J , re. ,5: ,1•Y 1 ,d .} r^r , •'4�1 � •t.-. +f • ` .Tll , i 5 J� q pewr � , �, i ,. 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'`,t , + t i ) 1 F^ o 1&7-1-1. • �i ' > ,-.L.d[".i ��.• • x 1 CITI Of Utn'J.DING DEPT. u , 1 4 — THESE :ORAW{tJ�,5 TO•BE , , • KEPT/A�7 U' NG �` , a -} y : INSPE� O E y . BJI y t . A '. - y. • � it e� � MY • rte, .t u •�' . w ,tni • 1 2 , i f f1.�i v • , r r , • _ S -_ __ .�-._.r+.� -.i., ..r_�+:i.TAY•,..•..-3•i,:rw•+•^+.��,-1+-x,4 '� 1/' �+M'.1p•++••.ri•'t.a1."'•'T'r+,•,+,.:_,'f+,. . r . . " ,i 1 • . : v 1 ,..v - Y • � .. Y `�, -.. � •i. • i •i , '. i �,�. + Irl i Y �.}d.• l'. w i F }` ! - r - ,; .S ( ° i..:ef ..•r ' . 'I. ,: ,E i. t :'f•'; 1 ' �i .:1-,( 4 f xp•tt. ,-f , _ Yl N—:� AV It ... 1 IJ S d-6 .FIR I�ovc4 To.t � go VI f;5TtNS1om • P'fA r G� rI Iu"�,t A T� aI IILI : � '. '.. � } - - - � Flt f�SiTiAG-•— �'�'� r , 4 '�° IP_ f A�If'PA' s -pH" f411 ; . f a �ov� r1JPF1 kill INV. �UrZqfploeg ` e� u X 7-1 5r +use . - 1 r � - '� Y'. = � � � � 2�!bpi (� l�Orr�.( . '�., la� , - I(pn�•� 1 CYY (+� � ' S , -- ------- - - — -- .-- - - ) � ti 1 , 1 . —� • �. , 4e:.• \\ \7 \ If �,. `, \, \�' l;. \ /jf +v,!v'4f ! i _. � i t I — 1 i. ✓I!I I 1 :�\ . `, �',1'.. i I �J l` :.• � J'F; 1 (I L _ ► ,t L I,' ite �'e 1>X _ x, I . s l 1 i f 1 �` � ' �'�`"` tib' � ��~� � ' • f 1 ' � � �" i , r MA sotj IjLLI rb '00000 00000, Lo'/ I , r r A l Plans must be filed and approved by the Inspector before a permit will be grants 61�5-y No. ;_�� City of Salem Ward IS PROPERTY LOCATED IN THE ;+ HISTORIC DISTRICT? Yes No� w a IF SIDING, HAS ELECTRICAL PERMIT BEEN OBTAINED? Yes NoA/ Home Phone # APPLICATION Bus. Phone # FOR PERMIT T ROOF, EROOF OR INSTALL SIDING Salem,Mass., TO THE INSPECTOR OF BUILDINGS: The undersigned herebv applies for a permi � t to build according to the following specifications: Owner's name and address _ atRS'. �9Y / 09<to-n/ //< Y S9[Eih- • Architect's name Mechanic's name and address fRF O `,,OA/ (G 1/,�A/t p c,f Location of building,No. &�I[rad Pl«'' y /-W What is the purpose of building? QFS iAFwI//t- _ Material of building? weon Asbestos? A/ If a dwelling,for how many families?_ / Will the building confonn to the requirements of the law? /r5 Estimwed cost S-000 Contractors Lic.No. D Sa s d Signature of applicant REMARKS SIGNED UNDER THE PENALTY OF PERJURY._ _ No. � Ward APPLICATION FOR PERMIT TO ROOF REROOF OR INSTALL SIDING Location PERMIT GRANTED 19 App rov d p c-a-r lc g Insp or V � 5' r !�� Ole40 @ � L �� G�taaa� o!��rraeaiws :ivv�gtirOYOSY ae.t:.f�a■.:. \tieham :j.cla�DttkaJtte aot.w�.�.tstus ,�raL � Aaam Keaaro rsutsumr caauz= seta Charly J. olac= cruor MEMORANDUM TO: Ag BUIW1n[ 04:2=UnCUC=121e 13ulWine tnsttetaara FROM: Charts J. Oineao Administrator DATE Cklooer J 1. 1793 SUBLET=T. MGT. cut. 154. Added Rw c4FA 59 of the nen Of19RT he accive•mentwnat statute rcautra mat ucora reuttlne tram she urmamton. rcuchmM&two sr nlner alteration tit a nutidinL ur Structure re UtinosCu (it in a p(OnQt7 Ip mcci, U" se0-dow ,atantT as UCCU t av MGL x:11. S1JClA asst that htsiustne prnnm ur uta esa are tU tttOOiaOO beta ,it the taaaty al Wella the saw dcnM n ut he utsptsseu. THIS REOUlRE:t4eMMIDER NQ APPLY TO NEW CONST iZU=7ON. In are= in si mOtiW the proms alw its Qn7VtUC aAttUrmtty. we are aoaCCina a Why ttl a MM va"vt taa ettnCr rcpmu=atw use as it U sal=inc tamnwttal Iurm will be attacnrn W Inc oi11Q GW O(budo permits or it- or rc;hoau= U on Asir icitcmc=L IIICMSCCI mttnit =L CCMmtr=L inuuslrtaL ur mutU•untt hnusmir tonstruttlon. the contraCM133IIPM MM the aummtCr sUnmmtaGor at lhC IIMC nt lnC oUitUlna jlcrmlt anpti=twn. In such c'=L tlwsuacb=M Of an AfQdavit an be ust= the mmmete taw is rnntalnco to the Nnvemuxr issue of CODEWORD wntctt Welt h mailed W"Mra in elm two ween it mu snouta have any uuettnn. ntcasc tct us know. UDlkm AFFfDAVTT As a result of the provisions of MGL c 40. S54. 1 acknowiedec that as a condition of Building Petmlt Number all debris resulting from the construction activity governed by this Building Permit shall be atsoosea of in a oroperiv licensed solid waste disposal facility, as defined by I40L c 111. S 150A. I certify that I will notifv the Building Official by CrWo months maumumI of the location of the solid waste disposal facility where the debris resulting from the said construction acuviry shall be disposed of. and 1 shall submit the appropriate form for attachment to the Building Permit /3 / Dam Signature of Permit APO= (Print or type the following information) Name of Permit Appfieant Firm Name. if auv l6 �,l�i✓(ar,� S�. S,y��� �2,A In accordance with the provisions of MGL c 40. S 54. a condition of Building Permit Number a that the debris resulune from this wore shall be disposed of in a property licensed solid waste disposal facility as defined by MGL c 111. S 150A- 7116 50AThe debris will be disposed of in: O (LA)cation of Facility) Signature of Permit Applicant g i �� Date COMMONWEALTH OF MASSACHUSETTS k DEFARTMENT OF ENDUSTRIAL ACCIDENTS _ 600 WASHINGTON STREET fames Gamooer, BOSTON, MASSACHUSETTS 02111 -omm ss one• WORKERS' COMPENSATION INSURANCE AFFIDAVIT (licenses/permiaee) with a principal place of business/residence at: /6- 3114«u? Oi S P (City/Stam/Zip) do hereby certify, under the pains and penalties of perjury, that: [ ] I am an employer providing the following workers' compensation coverage for my employees working on this job. �G6LJTEEN r.�C /NSS. r�� ro 6 F� QI -TC Insurance Company Policy Number [ ] I am a sole proprietor and have no one working for me. [� am a sole proprietor eneral contractor or homeowner (circle one) and have hired the contractors listed below who have t e o owing workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number [] I am a homeowner performing all the work myself. NOTE: Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto arc not generally considered to be employers under the Workers' Compensation Act(GL C. 152,sea. 1(5)), application by a homeowner for a license or permit may evidence the legal status of an employer under the Workers' Compensation Act. I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage venncation and that failurc to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to $1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of S 100.00 a day against me. Signed this / day of J, 19 vy Q , Licensee/Permiaet Licensor/Permittor