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66 DERBY STREET - BUILDING JACKET 66 DERBY STREET O E ONDITq,q CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT e. 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 TELEPHONE: 978-745-9595 EXT. 380 DOS FAX: 978-740-9846 KIMBERLEY DRISCOLL MAYOR October 11, 2010 To Whom it May Concern RE: 66 Derby Street According to our records, it has been determined that the property located at 66 Derby Street can be a legal grandfathered non-conforming 2 family dwelling with full renovations. This is to determine use only and in no way meant to confirm or deny whether said property is in compliance will all building, plumbing, gas, electrical, fire or health codes. Sn/4z;) Thomas St. Pierre Zoning Enforcement Officer s 1rTa.tn CITY OF SALEM, MASSACHUSETTS BOARD OF APPEAL 120 WASHWG'FON SrREEr, 3RD FLOOR �W t SALEM, MASSACHUSETTS 01970 TELEPHONE: 978-745-9595 FAX 978-740-9846 KIMBERLEY ORISCOLL MAYOR June 22, 2011 Decision Cry of Salem Zoning Board of Appeals Petition of JAY LEVY AND NEAL LEVY,TRUSTEES OF 66 DERBY STREET REALTY TRUST, requesting Variances from lot area, lot area per dwelling unit, frontage, lot width, front and rear yard setbacks,and off-street parking regulations, and a Special Permit to allow the reconstruction, extension, alteration and changing of an existing nonconforming two-family structure on a nonconforming lot to a single-family house, in order to subdivide the property located at 66 DERBY ST, Salem, MA, into two tots, construct an addition on one lot, and construct a new single-family home on the other(R-2 zoning district). A public hearing on the above Petition was opened on June 15, 2011, pursuant to Mass General Law Ch. 40A,§ 11. The hearing was closed on that date with the following Zoning Board of Appeals members present: Rebecca Curran, Richard Dionne,Annie Hams, Elizabeth Debski and Jamie Metsch, Petitioner seeks Variances pursuant to Section 4.0 (Dimensional Requirements) and 5.1 (Off-Street Parking Regulations), and a Special Permit pursuant to Section 3.3 (Nonconfornung Uses and Structures),of the City of Salem Zoning Ordinances. Statements of fact: 1. On March 25, 2011, the Salem Historical Commission voted unanimously to approve a conceptual plan that allowed the demolition of the rear addition existing on the house on 66 Derby Street,renovation of the remaining front main house, construction of a new addition and construction of one new two-unit building on the site. 2. After the Historical Commission issued their conceptual approval, input from the Director of Inspectional Services indicated that placing two principal structures Orr the sante residential lot would be problematic. The petitioners revised the plans to show the subdivided lot :and a new single-family house, rather than two-family house, proposed on the newly created lot. 3, Ind petition date-stamped June 1, 2011,petitioners requested dimensional Variances and a Special Permit to subdivide the property located at 66 Derby Street into two lots; alter the existing house on 66 Derby Street by removing a portion of it, constructivag a uew addition and converting it to a single-fainly house; :u1d COusn uct a lie single-hinny (tome on the other, lie wIN.cIeared lot. Petitioner,dso rc,questerl relief from Off-Street Parking regulations in order to allow tandem parking spaces and backing into a public way. 4. The petitioners were represented at the hearing on June 15, 2011 by Attorney Mark Glovsky. Architect David Jaquith and the petitioners were also present. 5. At the meeting on June 15, 2011, resident Angela Connery, 6 Connors Road, spoke in support of the petition. The Board also received a letter of support from At-Large Councillor Joan Lovely. A petition in favor of the project was also submitted. No one at the hearing opposed the project. The Board of Appeal, after careful consideration of the evidence presented at the public hearing, and after thorough review of the plans and petition submitted, makes the following findings: 1. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the zoning ordinance, since the proposed project's density is in keeping with the surrounding neighborhood, tandem parking is not problematic with single-family houses, and the proposed new house is intelligently sited and a positive addition to the neighborhood. 2. In permitting such change, the Board of Appeals requires certain appropriate conditions and safeguards as noted below. On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to,the Plans, Documents and testimony, the Zoning Board of Appeals concludes: 1. Variances pursuant to Section 4.0 (Dimensional Requirements) and 5.1 (Off-Street Parking Regulations), and a Special Permit pursuant to Section 3.3 (Nonconforming Uses and Structures), of the City of Salem Zoning Ordinances, are granted in order to subdivide and redevelop the site as proposed on the plans titled "Proposed Subdivision, 66 Derby Street, Salem, Property of Jay Levy, Neal Levy," dated May 10, 2011, and the plans and renderings titled "Proposed Restoration &Rebuilding of 66-68 Derby Street, Salem, MA," dated May 12, 2011. 1n consideration of the above, the Salem Board of Appeals voted, five (5) in favor (Curran, Harris, Metsch, Debski and Dionne) and none (0) opposed, to grant petitioner's requests for a Special Permit and Variances subject to the following terms, conditions, and safeguards: 1. Petitioner shall comply with all city and state statutes;ordinances, codes and regulations. 2. All constriction shall be done as per the plans and dimensions submitted to and approved by the Building Conunissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 3 4. Petitioner shall obtain a building permit prior to beginning any constniction. 5. A Certificate of Occupancy is to be obtained. 6. Petitioner shall obtain street numbering from the City of Salem Assessor's Office and shall display said number so as to be visible from the street. 7. Petitioner is to obtain approval from any City Board or Commission having jurisdiction including, but not limited to the Planning Board. 8. Unless this Decision expressly provides otherwise, any zoning relief granted does not empower or authorize the Petitioner to demolish or reconstruct the structure(s) located on the subject property to an extent of more than fifty percent (50%) of its floor area or more than fifty percent (50%) of its replacement cost at the time of destruction. If the structure is demolished by any means to an extent of more than fifty percent (50%) of its replacement cost or more than fifty percent (50%) of its floor area at the time of destruction, it shall not be reconstructed except in confornuty with the provisions of the Ordinance. 9. The renovated house on 66 Derby Street and the proposed house on the proposed newly created lot are to both remain single-family homes. Rebecca Curran,Chair Salem Board of Appeals A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the office of the City Clerk Pursuant to the Massachusetts General Laws Chapter 40A,Section 11, the Variance or Special Pernit granted herein shall not take effect until a copy of the decision Bearing the certificate of the City Clerk has been filed with the Essex South Registry of Deeds. Certificate No: 369-12 Building Permit No.: 369-12 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the SINGLE FAMILY DWELLING located at Dwelling Type 66 DERBY STREET in the CITY OF SALEM Address TowNCity Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY i 66 DERBY STREET This permit is granted inconformity with the Statutes and ordinances relating thereto, and expires unless sooner suspended or revoked. Expiration Date I � Issued On: Fri Aug 10, 2012 i0 ------------ GeeTMS®2012 Des Landers Municipal Solutions,Inc. ..— _.____.- --- ---------- _-_. ------ __- �� \ice,t.x p{Sg1ra'xcagttar�l✓a.;�.. _.. _... kk 66 DERBY STREET 369-12 �czs# 1119 r COMMONWEALTH OF MASSACHUSETTS Block: CITY OF SALEM fLot , 0098 •, o., Catego RLNO�:v1IONS ya Permit BUILDING PERIVIIT Project# l�JS;2012 000898 >; !Est. Cost ' $138,000.00 . - FeeChatted- tIS971b0 Balance Due ' t$ 00`r , �. PERMISSION IS HEREBY GRANTED TO: Contractor: License: Expires use Group: *a j'., �'"` _ 7 BEDROCK BUILDING CONS ULTANTSCONSTRUC['IO SUPERVISOR-030030 Lot Slze((�q ftI ,16811.9128 J Owner: Neal&Jay Levy �UnttsGamed'�g 'ram-+' 4 jApplicant: BEDROCK BUILDING CONSULTANTS AT: 66 DERBY STREET VmtsLost- ; _ 'I)i,;Safe# ISSL/ED ON: 17-Oct-2011 AMENDED ON. EXPIRES ON. 17-Mar-2012 10 PERFORJV THE FOLLOWING WORK: RENOVATION OF EXISTING BUILDING WITH NEW ADDITION ON REAR AS SHOWN ON PLANS jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET E_iectric Gas Plumbing Buildint! Underground: Underground: Underground: Excavation: Service: teter: Q• ° Footings: Rough: — /� ou h Rou h / wi t Foundation: Y' -� rZ' r / g '` g. 4'k � 'f+J' iCe:/✓Sl�' III i Final: ?/91/�2�� � Final: �• Final:0/1 g."),)-do ' /r�d/r}d Rough Frame: 1�}K v L' / p'I Fireplace/Chimney: D.P.W. Fir Health a,, xli Insulation: \Meter: Oil: •; �K- ��'✓ tvG1 C.• yI/ Final: li!o:aek -. Smoke: y/C/�� +ti •` ./t v l Treasurv: i iwatr'?: Alarm: Assessor ,e Scwer.'k,:� Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THF CITY OF SALEM(UPON VIOLATION OF A_NY OF ITS RULES ANI)REGULATIONS. Signature: ^q. Fee�TCylppeel:� -,_ Receipt No: Date Paid: Check No: Amount: ' ~ &Ob *[T:OWNER OR CONTRACTORC1��71-000995 17-Oct Al l 9J l -occupy $971.00 ARRANGE FOR PERIODIC INSPECTIONS DURING € "�1 rz7 ne$ to CONSTRUCTION.SEE CURRENT BUILDING CODE t"j1' elili °. CHAPTER 1 FOR LIST OF REQUIRED INSPECTIONS. CALL 97&619-5641 TO SCHEDULE AN INSPECTION C.fOT':1'Sir,29!! Des Lauriers Municipal Solutions,Inc. - - _.:.:E�e k Jl•�314J�V'yi�i(I �MdS . V_ ��w�W`'C7.'v`. .•. - s'FY _. W°S" '�' � _ .� �� V5QVE A0 CITY OF SALEM r BUILDING PERMIT ;jam Tity of *u1em, Massar4uoetts Ilublic Propertg Department +iguilbing Department (One ftem (6reen 500-745-9595 Ext. 300 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer June 9, 1995 Amelia Bik 66 Derby Street Salem, Mass . 01970 RE : 66 Derby Street Dear Mrs . Bik: This office has received several complaints concerning the property located at 66 Derby Street . On June 8, 1995 , I conducted an inspection of said property from the outside and would like to inspect the interior of the building to enable to see the structural status . Please contact me at the above mentioned telephone number, so we can arrange to meet at the site and gain access to the interior of the building. There also is an uninsured, unregistered vehicle in the yard that needs to be removed. You must also keep exterior of the property maintained by means of grass cutting and removing of debris . Please contact this office upon receipt of this letter as to set up an appointment. Failure to do so will result in legal action being taken against you. Thank you in advance for your anticipated cooperation in this matter. Sincerely, Leo E . Tremblay Inspector of Buildings LET: scm cc: David Shea Councillor Ahmed, Ward 1 Certified Mail # P 921 991. 730 CITY 4F SALEM ' + BUILDING DEPARTMENT EA/ us POST GE* CITY HALL ANNEX P 9 2.7, 9 9 7 7 3'D F ONE SALEM GREEN ?'�a 4; 0 2.5 2 SALEM, MASSACHUSETTS 01970 > ,_ '•:e..* .. 'i`^:s MA MMETER412154 *' "GtAi v7g —� 4AW 3St Notice Amelia Bik 2nd Notu Q 105 RetuWUN . /.."'� w :.,�4 �. . .sem .� ��e ..�.. .� ..d�:=� d�- t I United States Postal Service I � i Official Business � o I I PENALTY FOR PRIVATE F USE,$300 1 II INIINIII III III o1116JINJIII I11d1111116d61111 + INSPECTOR OF BUILDINGS I ONE SALEM GREEN i SALEM MA 01970-3724 i S i C SENDER: -I i • Compieitt ilams t and/or 2 for additional servie¢5. I a150 WISfi t0 receive the I� i' • on,Pleie nems m,and 4a a b. following services(for an extra fee): d • Print your name and address on the reverse of this for.so that we can return this card © Addressees Address to you. ' Attach This form ei the iroM of the ma mail¢,or on the back if nu does not permit 2 Restricted Delivery • Write"Return Receipt Requested i on the theilpieca below the pacearticle number. Y I • The Return R¢cegtt Fee will provide You,the sipnaiure of the Permn delivered to and the Consult postmaster for fee. i delivery I �.3..Article Addressed ressed to: 4a.Article Number I LINE,. P 9211 991 730 InI A }V 3 i 3 311h - 4b.Service Type 6 Aatc't, t'lnis. '?1"tYia CERTIFIED o M 7.Date of Delivery A Y. I x Pit 5.Signature=(Addressee) - 8.Addressee's Address M I (ONLY if requested and fee paid.) i I mature-(Ager 6/ k p� NnP zT 3811, avembplr]g9DT DOMESTIC RETURN RECEIPT i � I f I Titu of i$, ttlan. Massac4usetts Public Prupertp Department +iguilbing Department (One t3atem (5reen 508-745-9595 Ext. 380 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer June 9 , 1995 Amelia Bik 66 Derby Street Salem, Mass . 01970 RE : 66 Derby Street Dear Mrs . Bik: This office has received several complaints concerning the property located at 66 Derby Street . On June 8 , 1995 , 1 conducted an inspection of said property from the outside and would like to inspect the interior of the building to enable to see the structural status . Please contact me at the above mentioned telephone number, so we can arrange to meet at the site and gain access to the interior of the building. There also is an uninsured, unregistered vehicle in the yard that needs to be removed. You must also keep exterior of the property maintained by means of grass cutting and removing of debris . Please contact this office upon receipt of this letter as to set up an appointment . Failure to do so will result in legal action being taken against you. Thank you in advance for your anticipated cooperation in this matter. Sincerely, Leo E . Tremblay r/ Inspector of Buildings LET: scm cc : David Shea Councillor Ahmed, Ward 1 Certified Mail # P 921 991 730 �_ �_ �� � � ,1 / :__ � - r-- --- -- �`-� Y � '� �� POSTALE POSTMARK 00 DATE R RETURNSNOW TO WHOM.DACE AND RESTRICTED / a RECEIPT ADDRESS OF DELIVERY DELIVERY O SERVICE CERTIFIED FEE+RETURN RECEIPT WN 0 TOTAL P051AGE AND FEES Z DNI M NO INSURANCE C D- IDQ SENT TO. NOT FOR INTER NATIONAL MAIL LLQ O¢ a rc Amelia Bik ¢� 66 Derby Street x$ au Salem, Huss. 07470 01- Er a WQ EL, JZ aF PS FORM 3800 i RECEIPT FOR CERTIFIED MAIL � a uw scares - wsu s-- _ STICK POSTAGE STAMPS TO AR1ICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address of the article,leaving the receipt attached,and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified-mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REOUESTED 3r adjacent to the number. 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If return receipt is requested,check the applicable blocks in item 1 of Farm 3811. 6. Save this receipt and present it if you make inquiry. CITY OF SALEM NEIGHBORHOOD IMPROVEMENT TASK FORCE Jurisdiction Hist. Comm. Yes ❑ No REFERRAL FORM Cons. Comm. Yes ❑ No 11 SRA Yes ❑ No ❑ Date: Address: c Complaint: Complainant Phone#: Address of Complainant: DAVID SHEA, CHAIRMAN KEVIN HARVEY BUILDING INSPECTOR ELECTRICAL DEPARTMENT FIRE PREVENTION CITY SOLICITOR HEALTH DEPARTMENT SALEM HOUSING AUTHORITY ANIMAL CONTROL POLICE DEPARTMENT PLANNING DEPARTMENT ASSESSOR TREASURER/COLLECTOR DPW WARD COUNCILLOR DAN GEARY SHADE TREE PLEASE CHECK THE ABOVE REFERENCED COMPLAINT AND RESPOND TO DAVE SHE/ WITHIN ONE WEEK. THANK YOU FOR YOUR ASSISTANCE. ACTION: ' ARTICLE P 921 991 730 UNE I- . NUMBER Amelia Bik 66 Derby Street Salem, Mass. 01970 t FOLD AT PERFORATION t WALZ INSERT IN STANDARD#10 WINDOW ENVELOPE. C E R E I F IE D n M A I L E RW CIILJI�' f A ax t �;' Ctl CITY OF SALEM BOARD OF HEALTH Salern, Massachusetts 01970-3928 JOANNE SCOTT,IAPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(508)741-1800 Fax:(508)740-9705 February 21, 1997 Amelia Bik 66 Derby Street Salem, MA 01970 Dear Ms. Bik: The Health, Building and Fire Departments have received numerous complaints regarding property owned by you at 66 Derby Street. This property must comply with Massachusetts Health, Fire and Building Codes in order for you to live there. There are conditions visible from the outside of the house which seriously violate these codes, including fallen gutters, windows blocked with plywood, and unregistered cars in the yard. Conditions on the inside have not been determined. 0m ',r=Y OF SALEM HEALTH DEPAMENT i . 4 RT Nlne Noitti Street `'-" .3alem;Massachusetts 01970 ' There may be-some services available which will assist you. in fixing the building and complying with all Codes. The Health, Building and Fire Departments will conduct a joint inspection of your property on Wednesday, February 26,1997 at 10 Alli. In accordance with the "State Sanitary Code I: General Administrative Procedures, 105 CMR 4000.00" and the "State Sanitary Code IL• Minimum Standards of Fitness for Human Habitation," these inspectors are authorized to conduct such an inspection. We hope for your cooperation. However, in accordance with this Code if you refuse, impede, inhibit, interfere with, restrict, or obstruct entry and free access to every part of the structure, the Board of Health will seek a search warrant in Housing Court in order to inspect the premises. Sincerely yours, �(P 'J Joanne Scott Leo E.Tremb Charles Latulippe Health Agent Inspector of Buildings Fire Prevention Officer cc: Mayor Neil J. Harrington Delive ed by Poos i�ngg on main entranceto6 Derby Street cSiC9LtJ��i17�-2� 3 Tito of itWrw. massar4usetts Public Prayertq i9epartment Nuilbing 19epartment (One Belem (green 500-745-9595 Ext. 300 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer February 28 , 1997 Amelia Bik 66 Derby Street Salem, Mass . 01970 RE : 66 Derby Street Dear Ms . Bik: On February 27 , 1997 an inspection was conducted of the above mentioned property and the following violations were found : 1 . Unregistered vehicles must be removed from yard . 2 . Smoke detectors must be installed on the first, second and basement floors . 3 . All broken window glass must be removed and or repaired . 4 . Back stair rail needs to be repaired. 5 . Area way must be kept clean of overgrowth at rear entrance way and sidewalk. 6 . Maintenance of all exterior of building must be maintained. Please see that these items are corrected in a reasonable amount of time and contact this office after they have been corrected . Thank you in advance for your anticipated cooperation in this matter . Sincerely, Leo E . Tremblay / Inspector of But1dings LET: scm cc : Fire Department Health Department Jane Guy Councillor Paskowski , Ward 1 City of *afem, 4 ag!5acbu!5ett!5 Publit 3propertp Department 3guiibing department (One 6atem Oreen (978) 7459595 (Ext. 380 Peter Strout Director of Public Property Inspector of Buildings Zoning Enforcement Officer 6127141 Amelia Bik 66 Derby St. Salem, Ma. Re: 66 Derby St. Dear Ms. Bik: This letter is a zoning opinion that relates to the above mentioned property. As of this date your property is a single family residence because of the fact that the nonconforming use has been abondoned for more than two year. The information references the Salem Zoning Ordinance Article VIII Subsection 8-5 Paragraph#6 that states, any nonconforming use of land or structure and any nonconforming structure shall lose whatever rights might otherwise exist to its continuation under this section if said use or structure shall be abandoned or not used for a period of two years or more. In summary you should be taxed as a residence and not a commercial property. Sincerel l Peter Strout Zoning Enforcement Officer CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,3'FLOOR TEL. (978) 745-9595 FAY(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER March 5,2009 Amelia Bik 66 Derby Street Salem Ma. 01970 Mrs. Bik I was called to your property by the Salem Police Department on Tuesday,March 3,2009. At the property already was The Salem B.O.H Inspector,Dave Greenbaum, and City health Nurse Tracy Giarla. Two representatives of Elder Services were present and Salem Fire arrived shortly after that. All of the above were concerned about your safety.The Fire Department had to force open the front door as it was blocked by a makeshift wedge.After entry I was asked to look at your building. The first item taken care of was restoring the heat. The exterior of the building is in poor condition with visible wood rot and open eves in several locations. The side stairs,which constitute an exit from the second floor, are failing and both handrails are falling off. A look at the interior of this exit, showed that the door was barricaded with Appliances and various other items and would not be able to be used by you or by a first responder, trying to assist you. The only other route to the upstairs was through the Front door of the closed storefront, through the length of the Store and up through the narrow back hallway.The Store is loaded with old stock and various other items and at the narrowest point there is less than 20 inches of passegeway available. All of these conditions combined force me to declare the Structure" Dangerous and Unsafe"Massachussetts state Building code 780 C.M.R section 121.1. Before the building can be reoccupied, a building permit shall be pulled, repairs made and inspected, combustible load reduced to an amount acceptable to Fire Prevention,smoke and carbon monoxide detectors installed and tested by Salem Fire Prevention and a certificate of Occupancy to be issued by this office. If you have any questions, please contact me directly. Thomas Terre 4ZZ Building Commissioner/Director of Inspectional Services Cc Mayors Office, Salem P.D Sgt Rocheville, Fire Prevention,Electrical and plumbing inspectors, Salem Health Department City Hall,93 Washington Street,Salem,MA 01970 City Hall Annex,120 Washington Street,Salem,MA 01970 City of Salem, MA ix To: DahtiS ' GArlIlo- L"/�—From: Fax: 7R� - 512- y3/0 Pages: p� (Including this page) Dat /itq Phone: (978)745-9595 ext. Re: G �P7'�h sf- J�9/-al CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle y N A CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(508)741-1800 Fax:(508)740-9705 February 28, 1997 Amelia Bik 66 Derby Street Salem, MA 01970 Dear Ms. Bik: No health code violations were found within your residence at 66 Derby Street during our inspection on February 27, 1997. However, there were exterior violations: • Two broken storm windows on the second floor, front windows. -Debris accumulation which may create a rodent or raccoon harborage. -Others to be addressed by the Fire and Building Departments, including storage of unregistered automobiles, overgrown pathways and a loose hand railing. Please correct the window and debris violations within 30 days. Sincerely yours, Jo nne Scott Health Agent Posted an property and sent regular mail MEMORANDUM Date: 02/28/97 To: David Shea, Chairman of the Neighborhood Improvement Task Force CC: Councillor Peter Paskowski Councillor Thomas Furey From: Joanne Scott, Health Ager}t J .� RE: 66 Derby Street tUC The Neighborhood Improvement Task Force and the Health Department have received numerous complaints and calls regarding 66 Derby Street. Although the building appears vacant, an elderly woman resides there. Neighbors and others were concerned about the woman's safety within the building and whether the premises posed a fire or health hazard to the neighborhood. In response to these concerns, the Health Department attempted to inspect the premises with the consent of the owner/occupant. Access was denied. A search warrant was obtained, the Police Department provided necessary support, and access was gained on February 27, 1997. Police officers at the site were Detective Sergeant Thomas Griffin, Detective Peter Baglioni, Detective James Gauthier, and Officer Michael Levesque. Fire Prevention Officer Charles Latullipe, Building Inspector Leo Tremblay, and I performed our routine inspections within the building, including the first, second, and basement floors. No violations of Health, Fire or Building Codes were found within the building. The windows of the residence appear to be in poor condition. However, upon close examination, it was found that these windows include intact locks, screens and storms. Their poor appearance is due to the addition of plastic and chicken wire to the windows' exteriors. There were several exterior violations including the storage of unregistered cars, broken storm windows, and some debris and overgrowth. In conclusion, the Task Force may be satisfied that four City Departments addressed the issues of this property in a thorough and cooperative manner. The neighbors may be satisfied that this building is not a safety concern at this time. y W CITY OF SALEM HEALTH DEPARTMENT Nine North Street Salem,Massachusetts 01970 Th e may be some services available which will assist you u axing the building and complying with all Codes. The Health, Building and Fire Departments will conduct a joint inspection of your property on Wednesday, February 26,1997 at 10 AM. In accordance with the "State Sanitary Code I: General Administrative Procedures, 105 CMR 4000.00" and the "State Sanitary Code Il: Minimum Standards of Fitness for Human Habitation," these inspectors are authorized to conduct such an inspection. We hope for your cooperation. However, in accordance with this Code if you refuse, impede, inhibit, interfere with, restrict, or obstruct entry and free access to every part of the structure, the Board of Health will seek a search warrant in Housing Court in order to inspect the premises. Sincerely yours, J�iooanne Scott Leo E.Treml3l Charles Latulippe Health Agent Inspector of uildings Fire Prevention Officer cc: Mayor Neil J. Harrington Delivered by Posting on main entrance to 66 Derby Street 3 CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(508)741-1800 Fax:(508)740-9705 February 21, 1997 Amelia-B-il - !S 6 Derby Street Salem :: , MA_-01970 Dear Ms. Bik: The Health, Building and Fire Departments have received numerous complaints regarding property owned by you at 66 Derby Street. This property must comply with Massachusetts Health, Fire and Building Codes in order for you to live there. There are conditions visible from the outside of the house which seriously violate these codes, including fallen gutters, windows blocked with plywood, and unregistered cars in the yard. Conditions on the inside have not been determined. (situ of �ttlem, Aalwar4usetts Public PropertV Ile nrtment +'Builbing Urpartment (One dalem Green 500-745-9595 Ext. 300 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer June 9 , 1995 Amelia Bik 66 Derby Street Salem, Mass . 01970 RE : 66 Derby Street Dear Mrs . Bik: This office has received several complaints concerning the property located at 66 Derby Street . On June 8 , 1995 , I conducted an inspection of said property from the outside and would like to inspect the interior of the building to enable to see the structural status . Please contact me at the above mentioned telephone number, so we can arrange to meet at the site and gain access to the interior of the building. There also is an uninsured, unregistered vehicle in the yard that needs to be removed. You must also keep exterior of the property maintained by means of grass cutting and removing of debris . Please contact this office upon receipt of this letter as to set up an appointment . Failure to do so will result in legal action being taken against you . Thank you in advance for your anticipated cooperation in this matter. Sincerely, i O �_✓ CGS-rte' „/ Leo E . Tremblay Inspector of Buildings LET: scm cc : David Shea Councillor Ahmed, Ward 1 Certified Mail # P 921 991 730 �� Citp of *alem, fdag5arbu5ettg Public Aropertp Mepartment j9uilbing Bepartment One*atem green (978) 745-9595 (Ext. 380 Peter Strout Director of Public Property Inspector of Buildings Zoning Enforcement Officer June 28, 2001 Frank Kulik Assessor, City of Salem RE: 66 Derby Street Dear Frank: This letter is a zoning opinion that relates to the above mentioned property. As of this date your property is a single family residence because of the fact that the nonconforming use has been abandoned for more than two year. The information references the Salem Zoning Ordinance Article VIII Subsection 8-5 Paragraph#6 that states, any nonconforming use of land or structure and any nonconforming structure shall lose whatever rights might otherwise to its continuation under this section if said use or structure shall be abandoned or not used for a period of two years or more. In summary this property should be taxed as residential and not commercial. Sincer-11, ;G* Peter Strout Zoning Enforcement Officer (fitV of #alrm, Massar4usrtts Public Propertll i9epnrtment Nuilbing Bepartment (Ont dalem Green 500-745-9595 Ext. 300 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer February 28 , 1997 Amelia Bik 66 Derby Street Salem, Mass . 01970 RE : 66 Derby Street Dear Ms . Bik: On February 27 , 1997 an inspection was conducted of the above mentioned property and the following violations were found : 1 . Unregistered vehicles must be removed from yard . 2 . Smoke detectors must be installed on the first, second and basement floors . 3 . All broken window glass must be removed and or repaired. 4 . Back stair rail needs to be repaired . 5 . Area way must be kept clean of overgrowth at rear entrance way and sidewalk. 6 . Maintenance of all exterior of building must be maintained. Please see that these items are corrected in a reasonable amount of time and contact this office after they have been corrected . Thank you in advance for your anticipated cooperation in this matter. Sincerely, Leo E . Trembla}t / Inspector of BuYldings LET: scm cc: Fire Department Health Department Jane Guy Councillor Paskowski , Ward 1 Feb 28 09 10:17p Salem Police Department 9787405180 p.1 02/28/09 22 : 16 SALEM POLICE DEPARTMENT PAGE: 1 v5 . 50 INCIDENT REPORT TTYR073 -63 shift: C date: 02/28/09 SATURDAY org/1st ------------- ------------------------- --------- ---- ------------------ ----------- ********** R 185 CHECK WELL BEING **rcv*clr* 20 : 13 * 66 DERBY ST SAL 22A IBS *ibr: 1 : 20I 533552 * REPORTED HOME INVASION 11 * ID 4 : 3609 97 -63 InVO: BIK, AMELIA 02/05/32 66 DERBY ST SALEM,MA 01970 *** UNITS) *** 21 * SAL P PTL PHELAN OFF D GAIT 97 -97 r> 20 : 13 d> 20 : 13 a> C> 21 : 36 k> h> *** COMMENTS *** 21 SAL 20 : 13 : 56 CD-22A-REPORTED HOME INVASION 97 - 21 SAI, 21 : 36 : 02 CLEAR, REPORT TAKEN 97 - 21 SAL RESPONDED TO ABOVE LOCATION ON A REPORTED HOME 63 - 21 SAL INVASION. UPON OUR .ARRIVAL IT WAS EVIDENT THAT NO ACCESS 63 - 21 SAL COULD BE GAINED. DISPATCH WAS ABLE TO CONTACT AMELIA BIK 63 - 21 SAL WHO MET US AT THE FRONT DOOR. THE FRONT DOOR WAS COMPLETELY 63 - 21 SAL 63 - 21 SAL BLOCKED WITH PIECES OF WOOD. SGT. GAGNON WAS CALLED TO THE 63 -63 21 SAL SCENE AS WELL AS DEPUTY LYNCH FROM THE FIRE DEPT. _ THERE 63 -63 21 SAL WAS NO EVIDENCE OF A HOME INVASION. HOWEVER, THE HAZARDOUS 63 -63 21 SAL CONDITIONS OF HER RESIDENCE NEEDS TO BE ADDRESSES . DEPUTY 63 -63 21 SAL LYNCH RELATED HE WOULD NOTIFY FIRE PREVENTION AND THE 63 - 21 SAL BUILDING INSPECTOR. THIS OFFICER WILL NOTIFY ELDER SERVICES 63 - 21 SAL ON MONDAY IN ORDER TO FURTHER ASSIST MRS . BIK. 63 - -------- 1 -- G a ,. 5 officer' s signature date I 3 - 3c — cP I I aG � r�irJ ° Lz m I v Z:7 I ehr011ial'� 791 335 ,s33© 781 D--?e ssf 7 MCGEE & SCHIAVONI Fax 17815994310 Apr 6 2009 01:54pm /`001/003 McGee & Schiavoni 37 Friend Street, P.O. Box 311 Lynn, MA 01903 781-596-1090 Fax: 781.599-4310 FAX to: Thomas I St. Pierre, Inspectional Services Director, City of Salem fax: 978-740-9846 from: Thomas F. Schiavoni date: April 6, 2009 Ce: Guardianship of Ameilia Sik REQUEST FOR REPORT(S) pages: 3 , including cover sheet. Thank you for taking the time to explain the status of Amelia Bik's property at 66 Derby Street in Salem. As explained in our teleconference, I represent the guardian, Family and Children's Service of Gr. Lynn . I have enclosed a copy of the emergency court appointment. I would appreciate receiving copies (BY FAX)of any reports relating to the condition of the property or of Mrs. Bik's health and safety. cc: Gail Paris, LICSW CONFIDENTIALITY NOTICE: The document(s)accompanying this Fax contain information which is legally privileged. The information Is Intended only for the use of the recipient named above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the contents of this telecopled information except its direct deliveryto the Intended recipient is strictly prohibited. IF YOU HAVE RECEIVED THIS FAX IN ERROR, PLEASE NOTIFY US IMMEDIATELY TO ARRANGE FOR RETURN OF THE KGEE t SCHIRVONI Fax 178P.99d310 fpr 6 2009 01:541M P002103 qur sill[qq7 q`J: I ltll5tllbb14 LAM1LY&U iLL)Kt N b N41(it l ' Commonwealth of Massachusetts The Trial Court ES09k0863Gb Essex Division Probate and Family Court Department Docket No, ,,. TEMPORARY DFCREF OF GUARDIANSHIP GUARDIAN OF PERSON—AND ESTATE Name of ward Amelia Bik of Salem in the County of Essex At a Probate and Family Court held at S al on march 30, 2009 Amy L. Blake presided. (data) tnamaalttuEcej All persons interested having been notified in accordance with the law—Upon an ex-parte motion—and—no objections being made--'after hearing—upon representations of counsel,the ward—not--being present: The Court finds that the situation of the ward which requires emergency attention is mental 11luess and that the petitioners are seeking to avoid the harm of Amelia Bik The Court further finds that the ward: M is incapable of taking cam of h(no a herself by reason of mental illness. ❑ is mentally-retarded to the degree that helshe is incapable of making,informed decisions with respect to the conduct of his/her—personal—financial affairs and that failure o appoint a guardian would create an unreasonable risk to theward's health,welfare and property,and that the appointment of a conservator pursuant to G.L.M.c. 201,§16 would not eliminate the risk. [� is unable to make or communicate Informed decisions due to physical incapacity or illness. This temporary guardianship imides: Cl authorization to adtnito(committhe ward to a mental health or mental retardation facility,the action being in the best interest of the ward. ❑ the authority to consent to the following extraordinary medical procedure ci-P lit(10193) V'++al/Laa7 er7:a+ ra.taa.r beiv KGEE & SCHIAYQNI Fax 17815994310 Apr 6 2009 01:54pm p003/003 s tFia'i1l�Y2Sl:H 1LUKtiV 'u YHUC GL (BACK OF TFMPORARY GUARDIANSHIP DECREE) Thus, the Court determines that the welfare of the ward requires the immediate appointment of a temporary guardian and IT IS DECREED that: Family and Children's Services of Greater Lynn, Inc. {name al guamlan(1)) 71,1.➢Lo,*�tt�t'ammnn Gt T3rnn.. _.1'IA nton2 (elroot ad rw%) (dry or roan( (stele) 4o oode) and (name of euardlan(Z)) (street adoe") (dly or low l) Smete) be appointed the temporary guardian(4--of the person— and—the estate—of the ward pursuant to G.L,M, c-201,§ 14. The temporary guardian(*first giving bond W-With— mk--sureties for the due pertormanoe of said trust. THE APPOINTMENT OF THIS TEMPORARY GUARDIAN IS LIMITED TO A PERIOD 4W-+#NETY4M*S WHIe� rev eweAPTRF�510parti�es x �o appp appear at4Zf�v �` e, of a 3 3a�b�i Data .Probate and Fnmlly Cant Nvanmeat THE APPOINTMENT OFTHIS TEMPORARY GUARDIAN IS EXTENDED FOR AN ADDITIONAL NINETY DAY PERIOD AND SHALL EXPIRE ON Date JVayce of Prgbate artd Famey Court Depanmem (The Court may 90nd.lof addldonal ninety(90)day pedods the appolramant.provided that the 09ci vit of riam 'is properly made arra an Inverrtmry ar+dboret-ot been filed In accordance Whh'Probata Coun Rule 29D.) I, Pamela Casey O'Brien, Register,of Probate Court for Essex County do hereby certify that the foregoing is a true copy of a document on file in this court. MAR 3 1 2009 IN Nyr NESS, whereof I have s hand and affixed the seal of said Court this ESSEX SS , �,M�Q,, (�� PROBATE COURT �• •• 12r:n1",TPU r)V P-90PtATF A TRUE COPY CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 'Y 1 120WASHING ONSIREET 31"FLOOR TEL (978) 745-9595 FAX (978) 7=40'9846 Kfl%113FRL1--A` DRISCOLL MAYOR S'r.PIERR ., - DIRECR)R OE PUBLIC PROPERTY/BUILDING COMMISSIONER March 5,2009 Amelia Bik 66 Derby Street Salem Ma. 01970 Mrs. Bik I was called to your property by the Salem Police Department on Tuesday,March 3,2009. At the property already was The Salem B.O.H Inspector,Dave Greenbaum, and City health Nurse Tracy Giarla. Two representatives of Elder Services were present and Salem Fire arrived shortly after that. All of the above were concerned about your safety.The Fire Department had to force open the front door as it was blocked by a makeshift wedge.After entry I was asked to look at your building. The first item taken care of was restoring the heat. The exterior of the building is in poor condition with visible wood rot and open eves in several locations. The side stairs,which constitute an exit from the second floor, are failing and both handrails are falling off. A look at the interior of this exit, showed that the door was barricaded with Appliances and various other items and would not be able to be used by you or by a first responder, trying to assist you. The only other route to the upstairs was through the Front door of the closed storefront, through the length of the Store and up through the narrow back hallway.The Store is loaded with old stock and various other items and at the narrowest point there is less than 20 inches of passegeway available. All of these conditions combined force me to declare the Structure" Dangerous and Unsafe" Massachussetts state Building code 780 C.M.R section 121.1. Before the building can be reoccupied, a building permit shall be pulled, repairs made and inspected, combustible load reduced to an amount acceptable to Fire Prevention,smoke and carbon monoxide detectors installed and tested by Salem Fire Prevention and a certificate of Occupancy to be issued by this office. If you have any questions, please contact me directly. Thon s St.Pierre Building Commissioner/Director of Inspectional Services Cc Mayors Office, Salem P.D Sgt Rocheville, Fire Prevention,Electrical and plumbing inspectors, Salem Health Department c CK-1f 5-y 7 Y Hie Commonwealth of Massachusetts CITY OF a Board of Building Regulations and Standards y'� t SrNLC-M 1` Massachusetts State Building Code, 780 CMR a\v: 2erietd.I/ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demo rr One-or Twu-Funiily Drelling (:S EHThis Section For O E cial Use Onl Building Permit Number: Date Applied: Building Official(Print Name) Signalu Otto SECTION 1: SITE INFORNIATION 1.1 Pro erty Address: �. 1.2 Assessors M1lap a4r Parcel Numbers 1.1 a Is this an accepted street?yesy no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq fl) Frontage(11) 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: 1,11 Sewage Disposal System: + Zone: Outside Flood"Zone? I ❑ ublic'd _Private❑ Check if cs0 Munici Pal On site disposals)stem SECTION2: PROPERTY OWNERSHIP'2.1 OwL of Record: Name(Print) City.State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building( Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-: RF/Vdt/AT/O.t///L 6*5174e, Bls�7C W ICH N d�.4 O'eCAl� S.tX1t.V�l G.y COI Aw/�•— 1, SECTION 4: ESTIMATED CONSTRUCTION COSTS I tern Estimated Costs: Official Use Only (Labor and Nlaterials) I. Building 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard Cityrrown Application Fee '_. Electrical S �. ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S Z 0W'^ 2. Other Fees: $ 4. Nlechanical (IIVAC) S Pi coo —+ List: 5. Nlechanical (Fire S Total All Fees: S Su mression) Check No. _('heck Amount: ---Cash :\noun(--_-- 6. Total Project Cost: S 10(34�) ❑ Paid in Full ❑Outstanding Balance Due: - 61il/ we4_v R r t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ' NG//L L E�Y _-_ Liana Number I'_gtirmian 17atc Name of CSI. I folder 295 oo 06 - Sr List CSI.Type(Sec below) (/ No. and Street Tv Description IA" O,y�s llnneslricted(Buildin+s ti at 35,ono at. Il.l R Restricted IK217.... Dwdlin+ l'ilylrown.Stutc.ZIP M Mason RC Roolin C'ovcrin WS Window and Sidin SF Solid Fuel Burning Appliances MEAL LeV I Insulation "fete hone Finail address D Demolition 5.2 Registered Ilome Improvement Contractor(HIC) I IIC Company Name or I IIC Registrant Name IIIC Registrahcri Nunther P,piralion Date No. and Street Email address City/Town, State,ZIP 'rcic hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) 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 ..........6 No........... Cl SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT [1,as Owner of the subject property,hereby authorize �t/</act on my behalf,in all matters relative o wor horized by this bulldmg permit application. 1t/F�L G- GAT/JZD/I Pont Owner s Name(LlecWme Sigm re Dale SECTION 7b:OWNERt 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 in this applicatio nd accurate to the best of my knowledge and understanding. to Print Owher's nr whorizcJ.1genCs ante(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor (not registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty road under NI.G.L.c. 142A.Other important information on the HIC Program can be found at y)a-y,m:n..��rc i�ca Information on the Construction Supervisor License can be found at __ 2. When substantial work is planned, provide the information below: 'total floor area(sq. B.) 1750 _(including garage, finished basement'attics,decks or porch) Gross living area(sq. it.) f.�.��— Habitable romp count _ $_ Number of fireplaces / not 0 bed 0 ms - --- Numberofbathrooms 2.,9'—__ ---- Number ofhalfbadts --------_-- _---- 1)pe of heating System_F W A 6N--- ---.__-- Numbcr ofJecks, porches_ 0-------- "- -- Type ofcooling system (inclosed _ Open --- i "Total Project Square Footage"may be substituted, ror"Total Project Cost" Commonwealth of (Massachusetts Sheet Metal Permit AJ It Date: '- �� Permit # Estimated Job Cost $ / e/Ov- ry Permit Fee: 5 \� Plans Submitted: YES NO_ Plans Reviewed: YES NO Business License # Applicant License # Co 2- Business Information: Property Owner/Job Location Information: Name: fie- NameAz--,6/e/6G4 / Street:/370 cz"� 3C Si Street: 1je-P r y Sr City/Town: '//4 4J �!� City/Town: Telephone: �7�— �7� ����/ Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES ✓ NO s�arn��uc:u J-1 / M-I-unrestricted license J-2 / NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: 1-2 family `� Multi-family_ Condo/Townhouses Other Commercial: Off-ice Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. _ Number of Stories: Shect metal work to be completed: New Work: ✓ Renovation: I iVAC t/ Mehl Watershed Rooting_ Kitchen Exhaust System Metal Chimmney/ Vents_ Air Balancing Provide detailed description of work to be done: �� C Sfcr-c-, INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes❑ No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit Issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation Installation: YES NO Progress Inspections Date Comments Final Inspection Date Continents Type of License: By ❑ Master Title ❑ Master-Restricted CityiTown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fees/d3 ❑ Check at www.mass.govhipl Inspector ' nature of Permit Approval 1 / The Commonwealth of Massllcl)LISCl15 Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SA L LA I 'L•,� Revise,111ar 2011 Building Permit Application To Construct, Repair, Renovate Demolish a One-or Tnw-Familr Duelling This Section For Official Use nl Building Permit Number. ate Appled• _ �3 I Building Official(Print N;une) Signalu Date SECTION 1: SIA INFOR ON 1.1 Property AJdress: 1.2 Assam rs Nlap& Parcel Numbers !�6 ,r�FskozV ST I.1 a Is this an accepted street?yes no fap Number Parcel NumNxr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District 1'ropascd Use Lot Area(sq It) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards - Rear Yard Required I Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Check if yesEl Municipal kOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record•} N;mie(Print) C uy.Slate,I.IP Nb�GGbV'/' No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building K Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: >,(I SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and \laterials) y I. Building S � 1. Building Permit Fee: $ Indicate how fee is determined: '. Llcctrical S ❑Standard City/Town Application Fee ❑Total Project Cast'(Item 6)x multiplier x _ 7. Plumbing S ?. Other Fees: S \ 1. .\Ic'11.1 cal tll\':\CI S \- c Mechanical IFirC S Su iression) Total A11 Fees: S iCheck No. _('heck Amount: Cush Ainounl: 6. Tatal Project Cost: S ------ dt� ❑ Paid in Full ❑Outstanding Balance Due: 6 t r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) �Z 6 Z0/I L - --�--- - icense Number licpir;tlum Data N;u»o al'l'SI. Ihrlder 0300,30 List CSL I)pa(see below)__-____ No. and Street 1')PC Description I lnrestrictcd(Buildin,s ti to 35,000 cu. 11.) _ R Restricted l&2 FamilyDttdlin+ CigJfutt ni ' hl Masonry RC Rtx)in t Covering __ l W'S Window and Siding SF Solid Fuel ihuning Appllatll'aY G/l ri' I Insulation '1'cle hune 1[mail aJJmss D Dantnlitiun 5.2 Registered home Improvement Contractor(HIC) I IIC Registration Number lispiraion Date I IIC Compan) Nance or I IIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6)) 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 .......... ❑ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1.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 71b: OWNER' 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 in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Nurse(Flectrunic Signature) Date NOTES: I. :In Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor (not registered in the Nome Improvement Contractor(HIC) Program),will u�tt have access to the arbitration program or guaranty fund under %I.G.L.c. Iq'_A.Other important information on the HIC Program can be found at www mn>s.g.r ,,c.t Information on the Construction Supervisor License can be found at����tt.ncts<�,�� Vp, 2. When Substantial work is planned, provide the information below: Total floor area (sq. R.) (including garage, finished basennent'attics,decks or porch) Gross living area I sq. It.) Habitable room count Number of fireplaces.___ _ Number of bedrooms Number of bathrooms Number of half bads Number of decks, porches _-. .. ....._ _.. l')pc of coolln_g system Enclosed Open 1. "'loud Project Square Footage" may be substituted for''rolal Project C'osf.