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180 DERBY STREET - BUILDING JACKET 180 DERBY STREET , O ; �' c�ND1TA.Ad CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01 970- �� TELEPHONE: 978-745-9595 f FAX: 978-740-9846 KIMBERLEY DRISCOLL MAYOR Section 116.0 DEMOLITION OF STRUCTURES Structures over fifty(50) years old must have approval of the Salem Historic Society UTILITY DISCONNECTIONS REQUIRED orized Agent Date of Disconnection Water 13 (see attached requirements) Electrical Fire Health Sewer } '� Salem Historic Commission Dig Safe Numberj� Pest Control: ***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE PERMIT CAN BE ISSUED*** Fee for Demolition $5.00 application fee plus $2.00 per 100 square ft gross area, Minimum $25.00 City of Salem, Massachusetts .dire Department 48 Lafayette Street David 4N. Cody Salem, Massachusetts o197o-3695 Chieflel 978-744-1235 Fire Prevention 978-744-6990 - `faX978-745-4646 dcody@safem.com 978-745-7777 Demolition e Before a structure can be demolished, the Salem Fire Department shall conduct a preliminary demolition inspection, to ascertain any conditions which may require a fire watch* or other preventative measures to be taken before, during, or after the demolition process. Minimum of two weeks notice required to schedule appointment e A permit to demolish or remove a structure shall not be issued until the preliminary inspection has been conducted and a report of requirements necessary to prevent life safety hazards has been obtained by the applicant. s The inspection report shall include but not limited to: cutting and welding permit, fire watch, on site storage of materials, underground storage tank compliance.... e Proof of utility disconnects. e The requirements outlined in the report shall become a part of the restrictions of the demolition permit issued by the Building Inspector. *Fire watch patrol Salem Code of Ordinances Sec. 20-124 October 5, 2010 d CITY OF SALEM SALEM,MASSACHUSETTS vy�s 9i:- ENGINEERING DEPARTMENT 'r 120 WASHINGTON STREET, 4TH FLOOR /A�ryy DQ � SALEM, MA 01970 Phone: (978) 745-9595 x5673 Kimberley Driscoll Fax: (978) 745-0349 Mayor DAVID H. KNOWLTON, P.E. CITY ENGINEER October 25, 2011 Water,Sewer and Drainage Requirements Regarding the Demolition of Structures within the City of Salem In accordance with the provisions of the General Laws of the Commonwealth of Massachusetts and the Salem Water and Sewer Department, the following regulations governing the demolition of structures within the City of Salem shall be followed. This regulation is made in the interest of protecting the city's water, sewer, drainage and public way infrastructure at each connection located within the City of Salem, as well as to prevent conditions which may cause danger to public safety, result in water loss, or damage to city or private property due to water or sewer loss or back-ups, or cause pollution of the city's storm water receiving waters. 1. Prior to demolition of structure, a licensed plumber shall ascertain where all water, sewer and drainage lines are located entering and leaving said structure. The plumber shall make a determination of existing or prior use of each line, including, but not limited to domestic, commercial or industrial use; irrigation; fire suppression; sewer, stone drain or septic system; roof drain; or sump pump. After all lines have been located, the plumber shall make a formal written report with plans of all lines found to the City Engineer. 2. Once the plumber's report has been reviewed and approved by the City Engineer, a Registered Professional Civil Engineer (hereinafter referred to as "the Engineer") shall make a determination of the point of origin or discharge on each city main, for each line identified in the plumbers report. The Engineer shall also ascertain the location, use, and point of origin or discharge of any other lines on the property that may or may not be affected by the demolition or connected to the structure. The Engineer shall provide the City Engineer, for review and approval, a stamped plan of the property and adjacent City utilities, indicating the results of his investigations. 3. A request to the Department of Public Services, for assistance in shutting down any water main, prior to cutting and capping it, shall be made only after the City Engineer has approved the written reports and plans described above. ay i i Water, Sewer and Drainage Requirements Regarding the Demolition of Structures October 25, 2011 Page 2 4. Prior to demolition of the structure and immediately following item #3 above, a City of Salem licensed drain layer shall cut and cap the water, sewer and drainage lines at the city main and arrange for an inspection by the Department of Public Services prior to backfill. Backfill, compaction, temporary and permanent paving will follow to current city standards. 50 In the event that the lines will be used immediately after demolition for construction purposes, a set of plans and'or:hawings, s+tamped by a Registered Professional Engineer, describing the lines to be used during construction, must be provided to the City Engineer for review and approval, prior to obtaining a building demolition permit. Prior to receiving approval to re-use any lines, the lines shall be inspected for condition and capacity. Sewer and drain lines proposed for re-use shall be inspected by a Licensed Drainlayer with closed circuit television equipment and a copy of the resulting DVD shall be submitted to the City Engineer for review. Water lines proposed for re-use shall be inspected by a Licensed Plumber and a written report shall be submitted to the City Engineer for review. Any other lines identified shall be abandoned as described herein. 6. A demolition permit shall not be issued until the items above have been completed and the Department of Public Services has conducted an inspection and signed off on the water and sewer portion of the Building Department prerequisite Utility Disconnections Required Form. roved by: D H. Know n, P.E. City Engineer \\Salemdc0l\WaterAdmin\dknowlton\My Documents\miscellaneous\demo regulations water,sewer and drainage 1-30-09.doc I .............. ... ...........- Paul R. Lessard, Archited, NCARB .............. ... ......1.1-11-1 18 Leavitt- St. Unit 2, Salem, Ma 01970 (978) 210-1960 paul@paularchitect.com ...........�­........ ...... ............. www.paularchitect.com ........... .. ............. min M Mn Thomas St Pierre, Head Building Inspector City of Salem Inspectional Services 80 Washington St. Salem, Ma. 01970 May 31, 2013 RE: Controlled Construction at the The Brookhouse Home for Aged Women, 180 Derby St. Mr. St Pierre: Bettencourt General Contracting has successfully completed the bathroom renovation work at the Brookhouse Home for Aged Women according to the Architect's permitted drawings. Some changes were made by The Brookhouse during construction and 'as-built' drawings are attached showing these Code Complichanges. Sincerely, Paul R. Lessard, RA PROVIDE FLASHED OPENING W/ NURSE-CALL RAIN HOOD THROUGH EXTER. Q PULL-STATION BRICK WALL FOR FAN EXAUST. PROVIDE FLASHED OPENING W/ PAPER TOWEL RAIN HOOD THROUGH EXTER. DISPENSER NURSE-CALL PULL-STATION BRICK WALL. CD EXISTING DOOR TO REMAIN NURSE-CALL PULL-STATION E NSTALLOWATERPROOFCFARI� 'CAL' P A R I TI O N LEGEND Q Q ON TOP OF EXISTING SUB FLOOR. - 2"X2" NON-SLIP CERAMIC TILE U CEMENTITIOUS "MUD-JOB" SUBSTRATE FLOOR FINISH Lu co EXISTING PARTITION v/ I_ .2 SHALL BE INSTALLED TAPERING TO AS Lu DRAINS. FINISH FLOOR TILE SHALL BE FLOOR DRAIN BEARING WALL vU Q �- INSTALLED WITH "SUPERFLEX" TILE Q a MORTAR. (TYPICAL ALL BATHROOMS) <O Q NEW PARTITION °,. 1 Q Q SHOWER CONTROLS To 2 TO CEILING - b . W xxw SIDE OF WALL As 60' PAPER TOWEL Lu c:: O 5 6 0 rURN DISPENSER C/o j m NEW PARTITION WALL As 1Q As N� o TO CEILING ° Rq t - t'-6" CD FLOOR DRAIN vA xD Aa S J w _ cv 3 1 WHEELCHAIR ACCESSIBLE � A3 $ MARBo WITH LE COUNTER TOP SINK LJJ rn HAND a3 5 z ACCESSIBLE FAUCET & J d WHEELCHAIR ACCESSIBL DRYER RBLE COUNTER TOP O x o HANDLES, & FOAM HEA 00 WITH UNDERMOUNT SINK r- PROTECTION ON PIPES. ACCESSIBLE FAUCET & n HANDLES, & FOAM HEAT L.V 6�„ PROTECTION ON PIPES. A3 3 o NEW METAL OR SOLID PLASTIC 4'-0" RNN PAPER TOWELR Q 2-9° PARTITION FOR TOILET STAL DISPENSER 32" DR CLEAR OPENING (TYP) a A3 NEW PARTITION WALL PLUMBING RENOVATION TO 60 TO CEILING ACCOMMODATE DESIGN CHANGESlU 2 SHALL BE PER CODE. RNNc as Aa FLOOR DRAIN NURSE-CALLRq SIM. PULL-STATION ELECTRICAL RENOVATION TO S SIM. ACCOMODATE DESIGN CHANGESD �_ 2"X2" NON-SLIP CERAMIC TILE SHALL BE PER CODE. As Aa IM. FLOOR THROUGHOUT (TYPICAL) S 2"X2" NON-SLIP CERAMIC TILE HAND DRYER FLOOR FINISH 1 Q NEW FLOOR CONSTRUCTION (TYPICAL): INSTALL WATERPROOF FABRIC PROVIDE FLASHED OPENING EXISTING DOOR RAIN HOOD THROUGH EXTER.. ON TOP OF EXISTING SUB FLOOR. TO REMAIN CEMENTITIOUS "MUD-JOB" SUBSTRATESHALL BE INSTALLED TAPERING TO BRICK WALL. DRAINS. FINISH FLOOR TILE SHALL B INSTALLED WITH "SUPERFLEX" TILE XISIING DOOR MORTAR. (TYPICAL ALL BATHROOMS) TO REMAIN WHEELCHAIR ACCESSIBLE 4'-3" MARBLE COUNTER TOP I OBATHRM WITH UNDERMOUNT SINK, PLAN - RM 310 OBATHRM PLAN - RM 316 ACCESSIBLE FAUCET & OBATHRM PLAN - RM 317 1/2" = 1'-a' 2 1/2" = 1'-a' HANDLES, & FOAM HEAT 3 1/2" = V-0" PROTECTION ON PIPES. FURR-OUT WALL TO ENCLOSE EXISTING PIPE PROVIDE FLASHED OPENING W/ RAIN HOOD THROUGH EXTER. NURSE PULL-STATION BRICK WALL FOR FAN EXAUST. 0 QZQ NURSE-CALL PULL-STATION PROVIDE FLASHED OPENING W/ a NEW PARTITION WALL NURSE-CALL PULL-SRAIN HOOD THROUGH EXTER. TO EXISTING DOOR CEILING TATION BRICK WALL FOR FAN EXAUST. (n Z TO REMAIN H a NEW FLOOR CONSTRUCTION (TYPICAL): 1 -6" W INSTALL WATERPROOF FABRIC PAPER TOWEL 0 O ON TOP OF EXISTING SUB FLOOR. x 2"X2" NON-SLIP CERAMIC TILE DISPENSER w CEMENT111OUS "MUD-JOB" SUBSTRATE _ FLOOR FINISH W = 0r SHALL BE INSTALLED TAPERING TO A3 FLOOR DRAIN Lij W U DRAINS. FINISH FLOOR TILE SHALL BE INSTALLED WITH "SUPERFLEX" TILE (% N 2 MORTAR. (TYPICAL ALL BATHROOMS) L� CD 0 �- 6�' I PAPER TOWEL m w DISPENSERY W Q Q A3e C O ^ SHOWER CONTROLS TO 5 FLOOR DRAIN D Aa Rq �S t'_6" N W SIDE OF WALL as Z WHEELCHAIR ACCESSIBLE 0 O JLLj Q 3 n B _ MARBLE COUNTER TOP DD Q G= $�zA3 '-0" z WITH UNDERMOUNT SINK, m -r- N QJ A3 _ SSIBLE FAUCET HANDLES, & FOAM HEAT HAND WHEELCHAIR ACCESSIBLE PROTECTION ON PIPES. DRYER RBLE COUNTER TOP REVISIONS: WITH UNDERMOUNT SINK, 10 7 " MIN. ACCESSIBLE FAUCET & HANDLES, & FOAM HEAT INSTALL FLOOR UNDERLAYMENT A3 As 2-9" I ._ 2 NEW METAL OR SOLID PLASTIC 4/27/12 60„ ROTECTION ON PIPES. THROUGHOUT BATHROOM FLOOR Aa PARTITION FOR TOILET STAL 4-0 T� PAPER TOWEL PLUMBING RENOVATION TO 60 Aa 32" DR CLEAR OPENING (TYP) 1 5/31 /13 R ' DISPENSER ACCOMMODATE BE DESIGN CHANGES TGRyhc FLOOR DRAIN AS-BUILTS < 4 NEW PARTITION WALL Rq o A3 I TO CEILING 4 ELECTRICAL RENOVATION TO �o in NURSE-CALL ACCOMODATE DESIGN CHANGES PULL-STATION SHALL BE PER CODE. A3 5'-10" 18" MIN. 2"X2" NON-SLIP CERAMIC TILE HAND PROJECT DRYER 1Q EXISTING DOOR NUMBER: FLOOR FINISH TO REMAIN NEW FLOOR CONSTRUCTION !TYPICAL): DATE: 1 /16/12 INSTALL WATERPROOF FABRIC EXISTING DOOR ON TOP OF EXISTING SUB FLOOR. SCALE: 1/2"=1'-0" TO REMAIN CEMENTITIOUS "MUD-JOB" SUBSTRATE DRAWN: PRL SHALL BE INSTALLED TAPERING TO CHECK: DRAINS. FINISH FLOOR TILE SHALL BE PROVIDE FLASHED OPENING W/ b °� RAIN HOOD THROUGH EXTER. INSTALLED WITH "SUPERFLEX" TILE BRICK WALL. MORTAR. (TYPICAL ALL BATHROOMS) DRAWING NUMBER: WHEELCHAIR ACCESSIBLE �RFD agcy ' �\e Ja MARBLE COUNTER TOP p LESq T 9 WITH UNDERMOUNT SINK, G ACCESSIBLE FAUCET & * c 4 * /� HANDLES, & FOAM HEAT NEW FURRING `o SALQM, H l/�1 O ,/2 _ ,-o N ` RM 210 OPROPOSED BATHRM PLAN - RM 216 2 PROTECTION oN PIPES. PROPOSED BATHRM PLAN - RM 2 '?. Mass. Jyo BATHRM PLA 5 1/2° = r•0" PAPER TOWEL 6 1/2" = 1,-a' °yF Pia DISPENSER g1TN Of A1P`'�' Page 1 of 1 E1ec#rccl �nt�ie Bole switchbax 7 h ree-cy r 5let k¢P#ek y¢ Wg 040 d, DuOupiex I Rcedptneliit Receptacle WA `Wati pi oaf GFr puplex; � v °Is�+lateil'Grauritl Switched Pourrfee Ieceyitt ae 1 °` teem PuP#chard: , WC11-A - t"-d-R x F - , heti- . Li ht'Fix#ul'e4: f' gFrt:Fixtttre W.eatfierprataf F9t�oexcent d t�oil- Light'Fixtur �Lrghir P ere. ceiling :.a Cahsbinct�on � Power , Flecfirw 14'ator a :" .,�-vr« Vent Fati ftfok ,_ Cir'cuita Detectoi ' . E�reaker; Tel one ` ,iaor3sell x� ck ares Or.mer._ Do4rFelt; PLk}` {}' bn n r011n� http://www.make-my-own-house.com/images/Electricblueprintbigrev.jpg 5/9/2013 PROVIDE FLASHED OPENING W/ PULL-STATION NURSERAIN HOOD THROUGH EXTER. Q BRICK WALL FOR FAN EXAUST. PROVIDE FLASHED OPENING W/ PAPER TOWEL RAIN HOOD THROUGH EXTER. DISPENSER NURSE-CALL PULL-STATION BRICK WALL. EXISTING DOOR I 1 f� TO REMAIN NURSE-CALL PULL-STATION li 0� E • 0 NEW FLOOR CONSTRUCTION (TYPICAL): PARITION LEGEND Q Q t INSTALL WATERPROOF FABRIC f^ON TOP OF EXISTING SUB FLOOR. — 2"X2" NON-SLIP CERAMIC TILE v, U CEM ENTITIOUS 'MUD-JOB' SUBSTRATE 1 FLOOR FINISH rnLu SHALL BE INSTALLED TAPERING TO qs EXISTING PARTITION/ V♦ Lu ro Lu DRAINS. FINISH FLOOR TILE SHALL BE FLOOR DRAIN BEARING WALL INSTALLED WITH "SUPERFLEX" TILE Q MORTAR. (TYPICAL ALL BATHROOMS) W M UU a 0 NEW PARTITION a SHOWER CONTROLS TO 2 TO CEILING _ �, rr L w SIDE OF WALL as Q Lu x 60' I PAPER TOWEL o NEW PARTITION WALL as Q 6 1 TpRNNC " DISPENSER d TO CEILING O FLOOR AI Q L00 DRAIN A a as S J W A 3 Q v SIM. WHEELCHAIR ACCESSIBLE rl asA 0 8 MARB_ a WITH LE COUNTER TOP SINK w HAND EELCHAIR ACCESSIBL As 5 ACCESSIBLE FAUCET & a DRYER RBLE COUNTER TOP o =o HANDLES, & FOAM HEAl 00 WITH UNDERMOUNT SINK, PROTECTION ON PIPES. r ACCESSIBLE FAUCET & HANDLES, & FOAM HEAT 7 so„ PROTECTION ON PIPES. a3 A3 1O NEW METAL OR SOLID PLASTIC 2'_9" PARTITION FOR TOILET STAL a-0' o lURR q PAPER TOWEL 32" DR CLEAR OPENING (TYP) DISPENSER w A3 �pS NEW PARTITION WALL PLUMBING RENOVATION TO 60° TO CEILING ACCOMMODATE DESIGN CHANGESTU 2 NURSE-CALL SHALL BE PER CODE. RNNG as Aa FLOOR DRAIN Rq SIM. PULL-STATION ELECTRICAL RENOVATION TO S SIM. ACCOMODATE DESIGN CHANGES g 3 SHALL BE PER CODE, as as 2"X2" NON-SLIP CERAMIC TILE SIM. FLOOR THROUGHOUT (TYPICAL) HAND 2"X2" NON-SLIP CERAMIC TILE DRYER FLOOR FINISH 1 Q NEW FLOOR CONSTRUCTION (TYPICAL: INSTALL WATERPROOF FABRIC PROVIDE FLASHED OPENING EXISTING DOOR RAIN HOOD THROUGH EXTER.. ON TOP OF EXISTING SUB FLOOR. TO REMAIN CEMENTITIOUS "MUD-JOB" SUBSTRATESHALL BE INSTALLED TAPERING TO BRICK WALL. DRAINS. FINISH FLOOR TILE SHALL B INSTALLED WITH "SUPERFLEX";71LE XISTIN ' DOOR MORTAR. (TYPICAL ALL,BATHROOMS) TO REMAIN WHEELCHAIR ACCESSIBLE 4-- MARBLE COUNTER TOP WITH UNDERMOUNT SINK, OBATHRM PLAN - RM 310 OBATHRM PLAN - RM 316 ACCESSIBLE FAUCET & OBATHRM PLAN - RM 317 1/2" = 1'-0' 1/2" = 1'-a' HANDLES, & FOAM HEAT 3 1/2" = 1,a, PROTECTION ON PIPES. FURR-OUT WALL TO ENCLOSE EXISTING PIPE PROVIDE FLASHED OPENING W/ RAIN HOOD THROUGH EXTER. NURSE PULL-STATION BRICK WALL FOR FAN EXAUST. N - . Z NURSE-CALL PULL-STATIONPROVIDE FLASHED OPENING W/ i NEW PARTITION WALL RAIN HOOD THROUGH EXTER. CL NURSE-CALLPULL-STATION BRICK WALL FOR FAN EXAUST. 0 Z EXISTING DOOR TO CEILING TO REMAIN - � 1._6. W Q NEW FLOOR CONSTRUCTION (TYPICAL): PAPER TOWEL N Z INSTALL WATERPROOF FABRIC ON TOP OF EXISTING SUB FLOOR. 2"X2" NON-SLIP CERAMIC TILE DISPENSER F- w FLOOR FINISH W = CEMENTITIOUS "MUD-JOB" SUBSTRATE 1 w W U SHALL BE INSTALLED TAPERING TO qs FLOOR DRAIN � N O DRAINS. FINISH FLOOR TILE SHALL BE INSTALLED WITH "SUPERFLEX" TILE O N 0 MORTAR. (TYPICAL ALL BATHROOMS) i F_ 0 b m 2 s0" I PAPER TOWEL m w q3 6 0 1 l�RR/N In DISPENSER W Q 5 FLOOR DRAIN v x A A3 Ln as C SHOWER CONTROLS TO a S Z O W LLI SIDE OF WALL qs A WHEELCHAIR ACCESSIBLE 0 J 0 MARBLE COUNTER TOP Q:� D0 Q 0: WITH UNDERMouNT As I'Dza ACCESSIBLE FAUCET (INK, m V) g HAND x o HANDLES, & FOAM HEAT WHEELCHAIR ACCESSIBLE REVISIONS: DRYER PROTECTION ON PIPES, RBLE COUNTER TOP WITH UNDERMOUNT SINK, 10 7 • 'Mw. ACCESSIBLE FAUCET & HANDLES, & FOAM HEAT as As i NEW METAL OR SOLID PLASTIC 4/27/12 INSTALL FLOOR UNDERLAYMENT 2'—g" 2. �/�, ROTECTION ON PIPES. THROUGHOUT BATHROOM FLOOR as PARTITION FOR TOILET STAL / \ 4'-0" r�RR/Nc PAPER TOWEL PLUMBING RENOVATION TO 60 A4 32" OR CLEAR OPENING (TYP) 1 5/31 /13 c Rqp✓S DISPENSER ACCOMMODATE BE PER COSIGN CHANGES TGRyNc FLOOR DRAIN AS-BUILTS a NEW PARTITION WALL o A3 : TO CEILING Rgp2 � 4 ELECTRICAL RENOVATION TO NURSE-CALL ACCOMODATE DESIGN CHANGES g PULL-STATION SHALL BE PER CODE. As 5'-10" 18" MIN. 2"X2" NON-SLIP CERAMIC TILE HAND PROJECT DRYER 1Q EXISTING DOOR 7 NUMBER: FLOOR FINISH TO REMAIN NEW FLOOR CONSTRUCTION (TYPICAL); DATE: 1 /16/1 2 INSTALL WATERPROOF FABRIC EXISTING DOOR ON TOP OF EXISTING SUB FLOOR. SCALE: 1/2"=1'-0" TO REMAIN CEMEN11TIOUS "MUD-JOB" SUBSTRATE DRAWN: PRL SHALL BE INSTALLED TAPERING TO CHECK: DRAINS. FINISH FLOOR TILE SHALL BE PROVIDE FLASHED OPENING W/ °� RAIN HOOD THROUGH EXTER. INSTALLED WITH "SUPERFLEX" TILE BRICK WALL. MORTAR. (TYPICAL ALL BATHROOMS) DRAWING NUMBER: �ti¢Eo ARc WHEELCHAIR ACCESSIBLE ��9 J� aLESsq MARBLE COUNTER TOP WITH UNDERMOUNT SINK, *1/2 = 1.0° PROPOSED BATHRM PLAN RM 216 NEW FURRING ACCESSIBLE FAUCET & o rM 4 y OBATHRM PLAN - RM 210 HANDLES, & FOAM HEAT ass. A2 1/2.. = 1.0., O - PROTECTION ON PIPES. O PROPOSED BATHRM PLAN - RM 21 3' 4 5 PAPER TOWEL 6 1/2" = V-0" 44 OF A7A`'SP DISPENSER 1 hVne Alarm Service Ticket 424 Essex StreetScheduledor: Lynn, MA 01902-3624 Created By:fdow on 11/16/2009@ 11:03:15 AM (781)595-0000 TELA�/ n I AL11RM nD^� Ticket Number System Account Secondary Account (781)215-5310 FAX WA NE www.waynealarm.com 82456 MASTER BOX 153 Technician Panel Type Service Level Hart,Jonathan M SK 5207 Service Contract To: BrookhOuse Home System Type Panel Phone# Keys on File Fire N Salem, M 01970 Street Salem, Monitored By Panel Location Problem Code (978)7444--0219 SalWayne Alarm Systems Inspection-Fire : Warranty Level, fast Scheduled Date CS Phone# Expired 12/11/2009 ��� - u�g�� i ' 1� F�InspeGtlO NOt2S,EX + r,: -s.•a :5,: 2»ro!:.fi.„... ii x< ........- Contact: Sue?', . SYstem�om�pr ents µ ,: Cross Street: SItCi:COnlnlenlS' ° s` xN �. "i ,a? ..1'mVY'.xr2(s t'ltib''WMOMt" M7.�' . ? s as 4r, ^S'f .;�Ins .ua`„ ra y'm' d” yv "�fi`° , r�* .;✓ i r n waxy kJ�t`^7 .a Prob em Inspection„=„Flte;,.. �r� r �,a .r.. V 'FIRE INSPECTION-SEMI ANNUAL 7, r*a RV Service Performed x,'t a`� { 1 tVw rrra,.. mow.,... r ,4 hx; �,ii 3dlt"s .a uiiwtwt�. `.txuf 4'1, J�2. .�'i J 'Ms'fd i,`G• br; �\ l.-�,J k10 IU.wmw-W, 4cl cf, �6 _ _ {y Flcv n✓ h« K i �S—i NmM6ae Y er m,,�rtrT' "kp; +3�i!"ro.?` �ku`''"t " t•°a e' -r` me- 9't ^ fir” ,,Eguipment;List ,,� •; � � ' �,, ;:; h . Ap ointment Infbrrnatlon �,. mss,r � ,,. t.�., ,wl.,.,.., ��.. a , Quantity Parts# Description Location Serial# ' Technician mate Arrived Departed Hart Jonathan 1jHgQW9 \ h kg C` ni4t sp This ticket has been read and Fully understood by me. Furthermore, any questions concerning this ticket has been fully answered to my satisfactionand I have received a copy of this fully executed ticket.Test your systems regularly! For more information;contact our Service department.We ,ighly recommend you have a tesUinspection program to ensure continued operation. i Authorized Signature T, ! �) ^,!� �� Date Printed Name Title � � � � `� (2 W' Wayne Alarm Systems, 424 Essex Sfreet, Lynn,.MA 01907 r r r, 781.595.0000 WWW.WAYNEALARM.COM` Lic. C1111 Customer: Contact: khou5e owe Address: Contact#: AO c Sit. S(k�Ni Account#. 2nd Account#: Radio Type: Inspector(s): /( ' City Box'#. r notice? N� J Test Type: FRCP Tvpe: 1 Q S A Prima !`V FRCP Location:'7'& (`'t Secondarv#. Initiating Devices Device Type CircuitStyle., Quan. Tested Quantity Installed as S�,DI<es 655 C ZD v _P{ V Notification Devices Device 1-ype Circuit style Quan. Tested Quantit Installed Bells Horns Strobes ' Speakers Horn/Strobes ' Breaker Location: Breaker Sizer - FRA—Hea—size,77Z 7 FT Battery Voltage: V S StandbvCurrent. Alarm urren : Battery Date 1� Time: Parts Used: ' First Alert Honeywell \SECl/R MS' - Authorized Security Dealer AUMonzed Dealer - _ r, ` ,V RNING! I 1 I 1 1 (( 81)) 5-0000 1111 • IBM M Ml 010� ` � i. � ,IIS • j IN � ®a Report of Inspection/Test Annual Wet/Antifreeze SPRINKLERCARPORATION July 06, 2009 PROTECTING PROPERTIES SINCE 1903 Property Owner/Agent 58 Rear Pulaski St. 722 East Industrial Park Dr. #12 Brookhouse Peabody,MA 01960 Manchester,NH 03109 180 Derby St T:978-532-2907 F:978531-2433 T:603-626-7520 F:603-626-7524 Salem, MA 01970 Conducted by: Barger Scott Inspection Ref:288 Paul Murray (978)744-0219 k gkkp irl,�,. `�'n'3 :F,- f V i•,,,,F ..e� C t.,y� - Inspector-Printed nspe or- igna urey a s 111,state that the information on this forth is correct at the Scott Barger time and place of my inspection,and that all equipment tested at this time was left In operational condition upon completion of this inspection except as noted. Oro X Prop Glyc a Antifreeze type -16 Freezing temp of antifreeze Yes Freezing temp correct? Prop Glyc .e Antifreeze type -13 Freezing temp of antifreeze Yes Freezing tem correct? Pr p Glyc $ Antifreeze type � � -15 Freezing temp of antifreeze Yes Freezing temp correct? e Prop Glyc Antifreeze type -1 Freezing temp of antifreeze No Freezing temp correct? The antifreeze should be recharged. Yes Gauges on wet&dry pipe systems in good condition and showing normal water supply pressure? No Gauges less than five ears old ? Yes Alann panel received a signal from all water flow detection devices. NA Alarm panel received a signal from all control valve tamper switches. NA Electric bell operated. NA Water motor gong operated. No Fire alarm homs tested. Yes Sprinkler system alarmNthweltpWping? ephysical dama e. ( . Akis Yes Adequate heat in areas Print 7/7/2009 (All "NO"answers are to be fully explained.) Page 1 of 4 Copywrite 20025 Life Safety Inspector,OnSite Software,Inc. Report of Inspection/Test Annual-Wet/Antifreeze SPRINKLER CORPORATION July OG' 2009 PROTECTING PROPERTIES SINCE 1903 Property: Brookhouse Owner: Inspection Ref: 288 Wre;'Delartment o Yes Visible and accessible? Yes Couplings and swivels not damaged and rotate smoothly? Yes Plugs or caps in place and undamaged? Yes Gaskets in place and in good condition? Yes Identification sign(s) in place? Yes Check valve is not leaking? Yes Automatic drain valve in place and operating properly? NA Interior free of obstructions(if caps are not in place) ? N14 Valve clapper operational over its full range (If caps are not In place) � 13MOMMOO rt^a axsa 7 ui:"i° i k ^" 6 "`In gd condition ? Yes Free of mechanical damage and not leaking ? Yes No external corrosion ? Yes Property aligned ? Yes No external loads? Yes Visible pipe hangers and seismic braces not damaged or loose? No Was an obstruction investigation conducted and the system flushed ? Yes Sprinkler wrench with spare sprinklers? Yes Proper number and type of spare sprinklers? Yes Sprinklers free of corrosion? Yes Sprinklers free of obstructions to spray pattems? Yes Sprinklers free of foreign materials including paint? Yes Sprinklers free of physical damage? Yes Are all sprinklers in service dated 1920 or later? NA Fast Response sprinklers in service for less than 20 years?If"no"test sample now and every 10 years. No Standard sprinklers less than 50 years old ? If no test sample now and every 10 years. Some of the sprinkler heads in the attic are from 1938 (approx 40 uprights 212) ; �!l�afl'tn ,. Yes Gauges show normal supply water pressure? Yes Free from physical damage? Yes Trim valvesin correct(open or closed) position? NA No leakage from retardin chamber or drains? NPON Connection Outlet Pressure(psi) Results System Flowed SizeO comparable Static Rid Static to prior test Wet 6" Main drain 2 76 65 76 Yes Description eType Secured rn v N0 J Print 7/7/2009 (All "NO"answers are to be fully explained.) Page 2 of 4 Copywrite 2002-5 Life Safety Inspector,OnSite Software,Inc. Report of Inspection/Test Annual Wet/Antifreeze SPRINKLER 1.CORPORATION July 06, 2009 PROTECTING PROPERTIES SINCE 1903 Property: Brookhouse Owner: Inspection Ref: 288 a x w Nn � Q v Description > Type Secured da �a OWW Main Control Valve Chart/Insp/Maint 2 OS&Y 6" Pad Locked Yes I Yes Yes Yes Yes Antifreeze loop#1 Control Valve Chart/Insp/Maint 1 OS&Y 12-1/2"1 None Yes I Yes I Yes I Yes I Yes Antifreeze loop#2 Control Valve CharUlnsp/Maint 1 OS&Y 12-1/2"1 None Yes I Yes I Yes I Yes I Yes Antifreeze loop#3 Control Valve Chart/lnsp/Maint 1 OS&Y 2-1/2"1 None Yes I Yes Yes Yes Yes Antifreeze loop#4 Control Valve Chart/insp/Maint 1 OS&Y 2-1/2"1 None I Yes I Yes I Yes I Yes I Yes Print 7/7/2009 (All "NO"answers are to be fully explained.) Page 3 of 4 Copywrite 2002-5 Life Safety Inspector,OnSite Software,Inc. Report of Inspection/Test Annual Wet/Antifreeze SPRINKLERW. CORPORATION July 06, 2009 PROTECTING PROPERTIES SINCE 1903 Property: Brookhouse Owner: Inspection Ref: 288 Deficiency Summary These items were deficient and do not meet the requirements of the applicable code at the time of the inspection. Items marked Recommendation are not required by the applicable code but are opportunities to improve the Life Safety of the property. MEMO11 .. j No Freezinkg temp correct? The antifreeze should be recharged. No Standard sprinklers less than 50 years old ? If no test sample now and every 10 years. Some of the sprinkler heads in the attic are from 1938 (approx 40 uprights 212) NFPA-25-2002 5.3.1.1.1 A Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals. Print 7/7/2009 (All "NO"answers are to be fully explained.) Page 4 of 4 Copywrite 20025 Life Safety Inspector,OnSite Software,Inc. fr `� CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,3" FLOOR TEL. (978) 745-9595 FAx(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STYIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER January 4, 2012 Association for the Relief of Aged and Destitute Women 180 Derby Street Salem Ma 01970 RE: code concern Dear Owners, This office received and confirmed a complaint regarding the condition of the wall alongside the left side of the property. The wall is leaning significantly and poses a threat to the public safety. Under the authority of the Mass State Building Code eighth edition, 780 CMR section 116; I am declaring this wall an "unsafe structure ". This section requires the owner to begin to make safe and or remove the unsafe structure within 24 hours of receipt of this notice. You are further directed to contact this office to discuss your plan for compliance. Failure to respond to this notice will result in Municipal code tickets and further enforcement actions If you have any questions, please contact me directly. Tho s St.Pierre Director of Inspectional Services/Building Commissioner cc. Jason Silva, COMPLETESENDER: COMPLETE THIS SECTION DELIVERY ■ Complete items 1,2,and 3.Also complete A. Si re item 4 if Restricted Delivery Is desired. X ent ■ Print your name and address on the reverse so that we can return the card to you. B. d by(Erin ams) C. Dyte of slivery ■ Attach this card to the back of the mailpiece, / or on the front if space permits r -'^ Wq k zi ) (` 1. Article Addressed to: D. Is delivery dress different from item 17 ❑Yes If YES,enter delivery address below: @1G0 3. Service Type ❑Certified Mail ❑Express Mail ' ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery!(Extra Fee) ❑Yes 2. Acle'N ber (transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1W UNITED STATES °'` _� t'A U '*. q • Sender: Please print your name, address, and ZIP+4 in this box City Of Salem Building Department 120 Washington Street Salem, MA 01970 c Ct� of 2I�PI1T, C 1cI55�IC�11I5P t5 sgccc„�,.cP'"ti' ire �1eNsrfmrnt 2-1r:ilituar!•ro X18 �Gafn�ette �trrct Joseph F. Sullivan . �$zdrm, 01970 Chicf 7/15/88 c . Ms._Norma_James_,_President Brookhouse Home 180-Derby-Street Salem, Ma. 01970 Dear Ms. James: — co As a result of the inspection you requested for June 21, 1988 and the fiie drill conducted on June 8, 1988 problems in your fire protection system were noted and shall be addressed as follows; 1. Sprinkler heads, installed approximately sixty-five years ago, shall be replaced. The entire sprinkler system shall be tested and evaluated by a licensed/approved sprinkler company. The last report of inspection on file with the Fire Prevention Bureau is dated September 23, 1983. These reports shall be filed with the Fire Prevention Bureau annually. 2. The fire alarm system is inadequate for this occupancy. A fire alarm designer should be retained to evaluate and redesign the fire alarm system in re- gards to the smoke detectors out side of the sleeping areas, as per 527 CMR 24.00. The plan shall be submitted to the Fire Prevention Bureau prior to being installed. 3. The fire/disaster evacuation plan does not provide an adequate procedure for the safe evacuation of the residents. Assistance from the Fire Prevention Bureau personnel is offered in formulating an adequate fire/disaster evacuation plan. 4. The Certificates of Occupancy and Health have both expired. These shall be renewed as soon as possible. 5. Trash is not allowed to be stored in area of means of egress. If the Fire Prevention Bureau can be of any further assistance please do not hesitate to contact us. Yours truly, / / �• �t-�ii.ylrili Robert Turner, Fire Marshal cc: Mr. Robert Moore, Director Mrs. Patricia Carney, Chairperson House Committee Building Inspector City Electrician h (�t#tt ofXPz�t, �rs�rc� e## �'", ✓ 3 `��� a''� lettrirttl �epttrtme 'z f';' ;69 ttui £/i y�,r``�utttr f c ct (IIify ?Eierfririnn lr�;�" 44 `IGafatiette "St. �$Ulem, 1$laes. 0197Q Area Q1aDe 617 745-5300 July 12 , 1988 Ms . Norma B . James , President Brookhouse Home 75 Orchard Street Salem, Massachusetts 01970 Re : Brookhouse Home - Home for Aged Women in Salem 180 Derby Street Dear Ms . James : After a thorough inspection , recommendations are as follows : Cellar: Install new porcelain lighting fixtures . Serving Room: Install three GFC I receptacles near sink area and a switch for wall light . Laundry Room : Install one receptacle near laundry table . Install 8 foot fluorescent light on ceiling and install a switch for closet light . Nurses Room : Install ceiling I`.-ght with a wall switch . Electric heat should be checked for proper operation . Second Floor Living Room : Install wiring for 220 volt air-condition . Tenants Room : Additional receptacles may be required in tenants rooms . The following is a recommendation to up-grade the electrical wiring and lighting fixtures : . At the present , there isn ' t any electrical code violations , however , please take the necessary steps to avoid extension cords in the tenants rooms . Do no use wall lights for plugging in extension cords . If this office can be of any further a istance , please do not hesi - tate to call . ov Yours truly , Paul M. Tuttle , City Electrician cc : Building Inspector , Fire Prevention Mrs . Patricia Carney , Chairman House Committee , Brookhouse Home Ralph Hobbs LICENSE OR PERMIT BOND °'CNA/insuro'j� e y aY 5l+ CONTINENTAL CASUALTY COMPANY TRANSPORTATION INSURANCE COMPANY NATIONAL FIRE INSURANCE COMPANY OF' HARTFORD TRANSrrCONTrrI��NPNTAL IINSURA10 PANY AMERICAN CASUALTY COMPANY OF READING,PENNSYLVANIA VALLE`71�t)R�GE IN'SIi RAR'C'E'tb PANY General Office: Chicago KNOW ALL MEN BY THESE PRESENTS, That we G. F. Sprague & Co. , Inc. , of Holbrook, MA hereinafter referred to as the Principal, and Continental Casualty Company a corporation organized and existing under the laws of the State of Illinois and authorized to do business in the State of Massachusetts as Surety, are held and firmly bound unto City of Salem, MA hereinafter referred to as Obligee, in the sum of Five Thousand Dollars and 00/100 ($5,000.00)_, lawful money of the United States of America, to the payment of which sum, well and truly to be made, we bind ourselves, our executors, administrators, successors, and assigns, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, That whereas, the Principal has made application for a license or permit to the Obligee for the purpose of, or to exercise the vocation of Sidewalk Permit NOW, THEREFORE, if the Principal shall faithfully comply with all ordinances, rules and regulations which have been or may hereafter be in force concerning said License or Permit, and shall save and keep harmless the Obligee from all loss o-r damage which it may sustain or for which it may become liable on account of the issuance of said license or permit to the Principal, then this obligation shall be void; otherwise, to remain in full force and effect. THIS BOND WILL EXPIRE Aril 15, 1989 but may be continued by continuation certificate signed by Principal and Surety. The surety may at any time terminate its liability by giving thirty (30) days written notice to the Obligee, and the Surety shall not be liable for any default after such thirty day notice period, except for defaults occurring prior thereto. SIGNED, SEALED AND DATED this 15th day of April 1988 G. F. Sprague & CO. INC. Principal By: O t Ly By: A.ttbrr�ey-i n-fact G-23172-A Thomas E. Di Giuseppe ; iL Cogtinental Casualty Company CNA For All I hr Conan,it m,•n1,1'nn Milk,- AN ILLINOIS CORPORATION POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT Know All Men by these Presents, That CONTINENTAL CASUALTY COMPANY, a corporation duly organized and existing under the laws of the State of Illinois, and having its principal office in he City of Chicago, and State of Illinois, does hereby make, constitute and appoint-. Wayne C. Jenkins, AS H. LaF�ame, Carole F. Jenkins, Thomas E. Di Giuseppe. Individually of Boston, Massachusetts Its true and lawful Attorney-in-fact with full power and authority hereby conferred to sign,seat and execute in its behalf bonds,undertakings and other obligatory instruments of similar nature In Unlimited Amounts - and to bind CONTINENTAL CASUALTY COMPANY thereby as fully and to the same extent as if such instruments were signed by the duly authorized officers of CONTINENTAL CASUALTY COMPANY and all the acts of said Attorney, pursuant to the authority hereby given are hereby ratified and confirmed. This Power of Attorney is made and executed pursuant to and by authority of the following By-Law duly adopted by the Board of Directors of the Company. "Article IX—Execution of Documents Section 3.Appointment of Attorney-in-fact.The President or a Vice President may,from time to time,appoint by writtencertificates attorneys-in-fact to act In behalf of the Company in the excecution of policies of insurance, bonds, undertakings and other obligatory instruments of like nature. Such attorneys-in-fact, subject to the limitations set forth in their respective certificates of authority, shall have full power to bird the Company by their signature and execution of any such instruments and to attach the seal of the Company thereto. The President or any Vice President or the Board of Directors may at any time revoke all power and authority previously given to any attorney-in-fact." This Power of Attorney is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of the Company at a meeting duly called and held on the 3rd day of April, 1957. "Resolved, that the signature of the President or Vice President and the seal of the Company may be affixed by facsimile on any power of attorney granted pursuant to Section 3 of Article IX of the By-Laws,and the signature of the Secretary or an Assistant Secretary and the seal of the Company may be affixed by facsimile to any certificate of any such power, and any power or certificate bearing such facsimile signatures and seal shall be valid and binding on the Company. Any such power so executed and sealed and certified by certificate so executed and sealed shall, with respect to any bond or undertaking to which it is attached, continue to be valid and bindino on the Company." In Witness Whereof, CONTINENTAL CASUALTY COMPANY has caused these presents to be signed by its Vice President and its corporate seal to be hereto affixed on this 2ISt_._ day of - August 19_87 . CONTINENTAL CASUALTY COMPANY Gsulr State of Illinois 1 �o•°d..r 6 County of Cook ( ss J. E. Purtell Vice President. On this 21st day of AUQUst 19 87 before me personally came J. E. Purtell,to me known, who, being by me duly sworn,did depose and say:that he resides in the Village of Glenview, State of Illinois;that he is a Vice-President of CONTINENTAL CASUALTY COMPANY, the corporation described in and which executed the above instrument; that he knows the seal of said Corporation;that the seal affixed to the said instrument is such corporate seal;that it was so affixed pursuant to the said instrument is such corporate seal;that it was so affixed pursuant to authority given by the Board of Directors of said corporation and that he signed his name thereto pursuant to like authority, and acknowledges same to be the act and deed of said corporation. NOTARY �IJIX_ / `r PUBLIC n Leslie A.Smith Notary Public. CERTIFICATE My Commission Expires November 12, 1990 I,Robert E.Ayo,Assistant Secretary of CONTINENTAL CASUALTY COMPANY,do hereby certify that the Power of Attorney herein above set forth is still in force,and further certify that Section 3 of Article IX of the By-Laws of the Company and the Resolution of the Board of Directors, set forth in said Power of Attorney are still in force. In testimony whereof I have hereunto subscribed my name and affixed the seal of the said Company this 15th day of ADrl1 la'_ 8_ Ro vert E.Ayo Assistant Secretary s'. Form 1-23142-8 - INV. N0, G 57443-A COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH DIVISION OF HEALTH CAPE STANDARDS AND REGULATION LONG-TERM CARE FACILITIES PROGRAM QUARTERLY FIRE. INSPECTION REPORT Convalescent or. NursinR Home City or Town Infirmary Rest Home E Public Medical Institution Charitable Home In accordance with the requirements of General Laws, Chapter 148, Section 4, the Home For Aged Women *Name of Institution located at 180 Derby St Salem Mass 01970 was inspected on 8-30-83 by Raymond T Dansreau Name of Fire Inspector Report of Inspection Condition satisfactory •at time of inspection. Y Approved v � gna , ure Disapproved Fire Chief cci Building Inspector (Salem) Original Report tot Health Dept. (Salem) Long--Term Care Facilities Program Institution Room 560-80 Boylston Street File Boston, Mass. 02116 Form #37 (S. F.P. B. ) (Rev. 3/79) l of fpttlem, fttssar4usrtts Public Prupertg i9epttrtmeut iguilDintt Department (One t3alem (green 500-743-9595 Ext. 380 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer April 25, 1995 Staley McDermet Proposed Addition Staley McDermet Associates Brookhouse Home for Aged Women 175 Essex Street 180 Derby Street Salem, Massachusetts 01970 Salem, Massachusetts Dear Mr. McDermet: I have reviewed the schematic plans submitted for a proposed addition to the Brookhouse Home for Aged Women, 180 Derby.Street, in Salem. The shematic plans submitted included two drawings titled "First Floor Plan (which-includes'a site plan) and "Second Floor Plan", and are dated April 24, 1995. Based upon these submitted plans, it appears that the proposed addition complies with all zoning require- ments except that as a current, pre-existing, non-conforming nursing home use, the Brookhouse Home will have to apply to the Salem Board of Appeals for a Special Permit to extend the non-conforming use. Very yTruly Yours, Leo Tremblay Salem Zoning Enforcement Officer Q�pQp�s✓p NWITIUt-I I 4-X241'15 Po OPE�tY _ i tNEs - I. t-oT. APE = 2�129� S.F. I . 77777 34 35 1 1 Poop 32 33 Px� OINK ww1eo t Ge t(+. � gcnvtr� Acnvrt � NUESE � -Z. 2 ` 29 I / I � 2b VI T Z5 1 i 24 �Na,t I i I 1 � 22 C-03.- sH EXI�T INC. 23 T i — {3P`:XJKI}OJ56 Hr2AS SNLCF-� I Imo+A , Pf-OPU` OSED PF oPEe�Y _ _ A 4E A IrlES �.F. �I(o Sn S> I loT AP-eA TOTAL. DoT ce-N&UY-e I, I°lo6F= 551. /�D()IT101J N`C= 2 ST021E5 m or- pwo 1 (Dbl 1 _ i M w ems. 2E t9� t I �) 1 13 GODrJY ' � AGTVITr j M W NUosE ' i Z I 6 % I I i to T I `1 i I I � tAM 6 CL, 'Sv,. '-A—N EXISTrtdCo Ul T �U I l 01 N TO 6E i 3 ¢ i PETi�INe� i IR�Y -,TQ�GT y Critu of 1�ttlem, fttssar4usetts Publir 13rapertn Department 'eGm� Nuilbinq Department (One t•alem (5reen 508-745-9595 Ext. 380 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer April 25, 1995 Staley McDermet Proposed Addition Staley McDermet Associates Brookhouse Home for Aged Women 175 Essex Street 180 Derby Street Salem,Massachusetts 01970 Salem,Massachusetts Dear Mr. McDermet: I have reviewed the schematic plans submitted for a proposed addition to the Brookhouse Home for Aged Women, 180 Derby Street, in Salem. The schematic plans submitted included two drawings titled"First Floor Plan" (which includes a site plan)and"Second Floor Plan", and are dated April 24, 1995. Based upon these submitted plans, it appears that the proposed addition complies with all zoning re- quirements except that as a current, pre-existing,non-conforming musing home use,the Brookhouse Home will have to apply to the Salem Board of Appeals for a Special Permit to extend the non- conforming use. Very Truly Yours, Leo Tremblay Salem Zoning Enforcement Officer Salem Historical Commission CITY HALL. SALEM, MASS. 01970 A�aIMML fit! CERTIFICATE OF HARDSHIP It is hereby certified that the Salem Historical Commission has determined that the proposed construction [ ] ; reconstruction [ ]; demolition [ ]; moving [ ]; alteration [x]; painting [ ]; sign or other appurtenant fixture [ ] work as described below in the . . . Derby Street Historic District. CNAME OF HISTORIC DISTRICT) Address of Property: f180i.-Derby::Stv Name of Record Owner: srookhouse Home for Aged Women DESCRIPTION OF WORK PROPOSED: Retention of vestibule as installed until 6/7/96 - of which it must be removed until 9/30/96 and each year between 5/30 and 9/30. This Certificate is renewable after 5 years. REASON FOR ISSUANCE OF CERTIFICATE OF HARDSHIP: [ ] 1 . The application affects only the building or structure on which work is to be done and not the historic district in general . [x] 2. The application is approved because it does not cause substantial detriment to the public welfare. [ ] 3. The application is approved because it does not cause departure from the intent and purposes of the amended historic district act. will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (Federal Laws , Ch. 40C) and the Salem Historical Commission. Dated: 6/8/95 SALEM HISTORICAL COMMISSION By Chairman Salem _177storicalCommission ONE SALEM GREEN, SALEM, MASSACHUSETTS 01970 (508) 745-9595 EXT. 311 FAX (508) 740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Derby Street Address of Property: f1"80 Derby v Street Name of Record Owner: Brookhouse Home for Aged Women Description of Work Proposed: Repair/Replacement of shutters on front facade in kind. All shutters which are repairable are to be repaired. If not repairable, shutters must be replicated exactly including spacing between slats and thickness of wood. Existing hardware to be reused Shutters to be hung so when closed slats would shed water. Shutters to be painted Essex Green. Repaint window trim white. No changes in color, material, design, or outward appearance. Non-applicable due to being in kind replacement/maintenance. Dated: l SALEM HISTORICAL COMMISSION By: The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. :::{: � �'�O Uc �Ob2 . .`~;. . �� The Commonwealth of Massachuse s��NAL SERy��ES � Department of Public Safety � � Massachusetts State Building Code(780 C�f 6;MAR �2 ��� � � Building Permit Application for any Building other than a One-or Two-Family�e�ng � � (This Section For Official Use Only) � � . � ' fl Building Permit Number: Date Applied: Building Official: � SECTION 1:LOCATION(Please indicate Block#and Lot#for IocaHons for which a street address is not available) � � / g�� 5'� sS ,�1�'1�l7/� o��7 (� �DK �1-c�US� � No.and Street City/Town Zip Code Name of Building(if applicable) � � � � �� � � � �� SECTION 2i PROPOSED WORK ����� � �� � Edition of MA State Code used� If New Construction check here O or check all that apply in the two rows below � Existing Building Repair Alteration ❑ Addition❑ Demolition�(Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: (� D EZ--- Are building plans and/or construcfion documents being supplied as pazt of this permit application? Yes . No ❑ Is an Independent Structural Engineering P r Review r � • �-y--/�p�� Yes ❑ No � ` BTf Descri tion of Pro osed Work: d�� ^ I � /`� ���T, �l�v-�� M �y- S �Ob , o u 11 , �-- - � a - v � Aj� ` � 'CES��/iL �" SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR � CHANGE IN USE OR OCCUPANCY � � Check here if an Exisfing�Building Investigation and Evaluation is enclosed(See 7S0 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): � � � � �� �� SECTION 4:BUILDING HEIGHT AND AREA � Existing Proposed - �--T� No.of Floors/Stories(include basement levels) &Area Per Floor(sq.ft.) '� Total.Aiea(sq.ft.)and Total Height(ft.) " � � � � � � � ��� SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 ❑ A-5❑ B: Business ❑ E: EducaHonal ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R3 ❑ R-4 ❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION 1'YPE(Check as applicable) � IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB � � SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) � � Water Supply: Flood Zone InformaHon: Sewage Disposal: y� Trench Permit: Debris Removal: Public�� Check if outside Flood Zone❑ Indicate municipal�l A trench will not be Licensed Disposal Sitep Private❑ or indentify Zone: or on site system❑ required �or trench or specify:_�E?]�-� permit is enclosed ❑ Q7� � Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commissiun Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes 0 or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edifion of Code: � Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: r. ��, �� � �'� c�� � ���� , • . � SECTION 9: PROPERTY OWNER AUTHORIZATION� . � � Name and Address of Property Owner 13+C'aaX��f�S� l-S'Cb JCj2��S/ 5'� � �-1-��'1 /��-- Ol9'7C) Name(Print) No.and Street City/Town Zip Property Owner Contact Information: y� (lS I li �� - - Title Telephone No. (bus� Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the ro ert owner's behalf,in all matters relative to work authorized b this buildin ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ��� . If bui]din is less than 35,000 cu.ft.of enclosed s are and/or not under Constructlon Control then check here�and ski Section 10.1 � 10.1 Re istered Professional Res onsible for Construction Control � p���� L�SS�� —]°-��� � n-� f� p Name Registrant � Telephone No. e-mail address Registration Number �d �f�l-��I ✓1'11� � treet Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor � � � /� � v�CYT��ICc�V]2-�— G'.0�1/� �=C� • Company Name �1 A� S � �3 _ ,��].►coUi2� c�o �3 � �yr (/�i/F,���sT-6� I�r�l ame of Person Responsible for Constructioia License No. and Type if Applicable �--D .�C-�u�2 � �� �1 Vl= ���.�D�� �DL��[� Street Address City/Town State Zip �-�-3-a-�� ����9�( 3 �����X'��va P G d an Tele hone No. business Tele hone No. cell e-mail address � � � SECTION 11:WORKERS'COMPENSAl'ION 1NSURANCE AFFIDAVIT (M.G.L..c.152.§ 25C 6 � � A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of Yhe issuance of the building permit. Is a si ed Affidavit submitted with this a lication? Yes No 0 � SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE � � � Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6) _$ � �C� 1.Building � ` � Building Permit Fee=Total Constxuction Cost x_(Insert here 2.Electrical $ $� D O-j�.: /�(� appropriate municipal factor) _$ 3.Plumbing $ 6-?jV , 4.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) 5.Mechanical Other) $ Enclose check payable to ��� �� � 6.Total Cost O O�� � � (contact municipality)and write check number here SECTI . 13:SIGNATURE OF BUILDING PERMIT APPLICANT . By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this a pl' atio is a ace ate to the best of my knowledge and understanding. � � � � .�`c ��u 2��-L— CO�s7`,e��'T/��v ,- bvb S �� S vPC R V l � �13. J����a�-9�� � l se pnnt and sign name Title Telephone No. � Date rz.i= - ���/�o�►� v �.—��2G J Street Address City/Town � State Zip Municipal Inspector to fill out this secflon upon application approval: __ � � Name ate �;�<t I , � � � � � � o � ti rn � / T O U �` • Q U �/ / � - Y U � L � . VJ ~ � � m 2 J fl- I �/%/%/;� %/ i y �///,%%�i%�//i '� ///% 2ie zi� W U Q � I / DN � �� `;/ i ///� " / D i%%%/� '% ��'%� ' / ��%%"�%�':. ' . � �� O_ ; . % �% ,�,� ,, ,;,�, �� r�� � ,,�. � i�ii � % J a J ' ' %i ❑ ' � � � ` � w � � ��� � � � ea zia eR 2is �„ �i' � %� ii/ � � %/�//i%%/� %%%i%� ��%//'///, o �' ;../ j. �,///' ' � W � � , i � � � ���i' � � W � � ! BR 218 BR 219 BR 220 % / ��/� �' c0 " � � LOUNGE 212 BR 213 _ � ���� � — � / . � � i! �� � � � . � �� % �j/ / � I V � � . I / i . �j . % j � . 223 i w � N . ' , /% � ; J � ' � �� � „ � , � , i, �I � ; � > � % . / �. � / .�I / BR 221 � BR 222 � . j � Q � ��'. : � / �,_,. ,�. 0 2 , ., . �% , N>. -�� ' �. . �., , j � � � % . � � � W �. _ � I - t._'. � E � � ./� , � > e �' PARLOR 22! %�� . � J = � ; j jj �v - % 00 a � % jj � � ,�, _ , , � ATTENDANT /� o" i/�ii,%%/' � . %j'/ � STATION '� ; � %` . �� � RAMP DN : , � � ; NUR;SE 211 BR 209 BR 208 �� BR 207 BR 208 BR 205 BR 204 � , ._ ,� . � / % O //, � /� � ���/�%%%i % �% %�- �/ :" a , � z j�//i�/'�%,:��//,��o i/"' % %' � , o / /%/ '%�/i/, %j ; � � � � / �i,/%//////�: %� , /� , � .,�i ' � i ;�' //'�%% � %i '//'. ///;%�%r.-, %/.'%%��, � Z � UP 2 , // / i ; , � o � , � � � z o , � ; / � � �, , ✓ � , — / ��.,. ��, %,., . /��%, „ , I� o o i3 i � � � s cE i � � 'i % ' i '' ?' j, //� '� � i / i� �; ; � ;/ ;, , ,, ' j % �j BR 203 �.� — jj BR 202 � BR 201 j% / STORAG /.. o //j �� � / / % �� / R � �j STORAGE STORAGE � ` � � ii /, % % / /,���� �%j//j / % ///,%'%��/� %%� "/ / ' j ",� % �a�%�/� /;�i i %%/i/i/i/'i D///i/ii/%%/"/�i/ii;/ � i � NURSE'S CALL SYSTEM PERFORMANCE SPECIFICATION: A NURSE'S CALL STATION EQUIPPED WITH APULL—CORD �2nd FLOOR PLAN i • . SHALL BE INSTALLED) NEAR EACH TOILET. EACH CALL ^� ��g�� = 1�_p�� - - ••—. ---. . -. --- -- - STATION MUST ACTIWATE AN EMERGENCY SOUND SIGNAL APJD VISUAL SIGNAL AT THE ATTENDANT STATION. THE SOUND SIGNAL AND VISUAL SIGNAL MUST REMAIN ACTIVATED UNTIL N AN ATTENDANT PRESSES THE "CANCEL" BUTTON IN THE Z Q BATHROOM WHERE A� RESIDENT PLACED THE CALL. A DOME � � HT WILL BE PLAC�D IN THE HALLWAY OUTSIDE OF EACH BA ROOM. THE FLASHING DOME LIGHT WILL BE ACTIVATED (n Q ,�i�i� „ii''/r/%j/' /jii�ij/ij/ ijiij�i�j/�i, i iii ;j AND ACTIVATED ALONG WITH THE NURSE'S CALL STATION F— z � � � � �/%/:/� !�'////ii'"/iii i�i%:�i/; %�//%/%�;i% 'i%` �%% �i°i��/r, i%i%�i� SI GN ALS. W �, / � i �� PHASE 1 � � j � ; ,; �j j __J �.�� � i i . ^ - - - - � � � U / / , � /, /, , :i % �i �: % r� i%%'�j'///'/%/ ////%%� W = w � FOOD STORAGE ��� FOOD STORAGE KIiCHEN I DISH RM I �� i-,�� ��� / � o i /���� � � %� / � / BUILOING & GROUNOS � Q Q �/ I I ��. �� � jj/i- ji � w V � i � OFFICE j � � � �j � i i� I I . ��i � Q W � I 00 ;j� I I . i � �. ; � . � �'^ � � �. � �� ��� i�: j� I . / I I / '�. � � V ! � W . � j � UP . � � � ,,, �� DINING RM � STAFF DINING RM LEVISION RM � � PARLOR � Q � j; � /i j i �. :'s i � 1 i � %i � � � � � ' . . �/%" /� / ; . � ,/i,i.,,i o,,,,.;. , � . ,. l —.— � %i � . . ,y,,, AREAS OF RENOVATION �, � m � w � � ��% /�; � �, SEE LARGE SCALE P�AN „ � � fn �� Hn�� UP � � ,- i, � e v. � DRAWING A2 � % �� W S . % �/�i NURSE S LL � � � ^ � j % �P % �' � STATIONS EMERGENCY W ' � � ❑ /%' //// i%%j�%� � p J � j I PHA DOME LIGHTS � N � o � � o � �� � N O � WVORK RM SiORACE . � � SiAFF OFFlCE � STOR. j STAFF BREAK RM � � � , j� � �, � � ,.. ", $ITTINC RM � � . � � � /.,..: � , .�. ,,, ._ ,.,. i i �b ! % � . VESTIBULE i � � � � � MAIN ENTRY HALL� � REVISIONS: � ./ � � � . � , � � % HALL �����������; � � . , O �, �� , - � %i%oiii%i%� i %%!i%i -- i%! i%///. %ii///// o %! a ; j/ i/� �" ; % ?i; ��r; j' % EMERGEf�VCY E / UP � �, ; � � o � , � OME LI�GHTS —/� ; � � �1 i - i j � Di%, . �ii ' „ , � � � � I I / ; � � � .., ,.. , .. ,,. . .- . �,.,;. ,,,,,:� , �_ __ , � � , , �, '� j i . , -� i � '' %// ///, %� � < % / i % � ' %� i � �;; � � % � � � � � % STORAGE � OFFICE � � � A�MINISTRATOR'S OFFICE MEETING RM �� / � � % � � 8 � e.� / ; � � ..,,�„ i � � PROJECT � ' ; � � � � 'i � � NUMBER: , , � � "i �nuHORv s� � / �� % DATE: 2�1 1 1 �16 � �� �� �� / 0 �j��%� ' � � SCALE: �/a"=i'-o., � vwrcn on�n w�siw / %� � � i�%" ;'%�'// '%%///%' % 'i/�� . o i �% i �:/i� i� % i ii� ,� i,/, DRAWN: PRL ;iiiii//ii//i ii/�%i� i CHECK: z 1 St FLOOR PLA , c,�SP�¢a e s4sr,� DRAWING NUMBER: ^' 1/8" = 1'-0�� �. Q � , � �A s� * � � M m � I/�' O ��•' �4�' . � \���1 , � �J, . � � `L �TyOFWtA`-�`'FG � ��' r ! � � . . . _k�.��. . ._.,:. � . . ::. ', _.,..� . �.. .: " . . � ' —�.... I ___� . .__... . —�. ..�. . .'_ . . . _.__ . ' . _ _ ._.. _ � ._�__. _ _ _ _ __ . ..�_.�_ ._c_,... . . . ._ . .._. ...._.. _ . ._._. ..__ . I , . . . . . . . . . .._. . ',. . I . I.... .._.�__._ . . . . . . , III , . '� . ___ �.�_ _ ___ . _ _____ � . � o � � rn � � T_ O O � � Q U � . � . . . - ' I _ � _ y V% � � � � � � , v�/ = J a � � � � Q PROVIDE fLASHED OPENING W/ � Q J RAIN HOOD THROUGH EXTER. BRICK WALL FOR FAN EXAUSL � �LJ W $._�., NEW GROUND FAULT INTERUPT ■ � w — ELECTRICAL OUTLET 42" AFF � � � o rn 0 � � � � � % %� � / JW � � / 0 � 0 � � �� 0 �c > � � • w � ._. o � o � J � / PAPER TOWEL FLUSH MOUNTED CEILING G FI 42 � WALL MOUNTE� LIGHTING � - � j A3 DISPENSER gUILDING C DE.�MPLY WITH FIXTURE ABOVE MIRROR � 6�., TCiR� CEILING MOUNTED LIGHT tic Rq��� NEW WA,LL MOUNTED SINK PULL-CORD NURSE'S ¢ S j WITH ACCESSBLE FLIPPER CALL STATION. � A3 2 TYPE FAUCET HANDLES � PARTITION BLOCK DOOR `� A3 �z i DEMOLISH PARTITION. ca = o REMOVE ALL PLASTER O OPENING & EXTEND WALL FURRING TO ACCOMMODATE AND LATH ALL BATHROOM GRAB BAR ATTACHEMENT CEILING MOUNTED WALL SURFACES & CEILING. SPRINKLER HEAD REMOVE PLUMBING FIXTURES. � REMOVE FINISHED FLOOR. A3 / 2"X2" NON-SLIP CERAMIC TILE FLOOR THROUGHOUT (TYPICAL) � / NEW FLOOR CONSTRUCTION (TYPICAL): � i � INSTALL WATERPROOF FABRIC / j ON TOP OF EXISTING SUB FLOOR. / , CEMENTITIOUS "MUD-JOB" SUBSTRATE FINISH FLOOR TILE SHAL BE / L / / INSTALLED WITH "SUPERFLEX° TILE ' jMORTAR. (TYPICAL BOTH BATHROOMS� � AMEHEIGHTYPEIRHCODECATED NEW DOOR WITH 32" DR / I „ EXI NG EXI NG ACCESSIBLE oARDW RE EXI NG / EL ,�TOR � EL TOR / EL TGR ; � , � FLUSH MOUNTED CEILIING FAN. CFM TO COMPLY! WITH �� ��� � � BUILDING CODE. � � / EXISTING SPRINKLER PIPE TO REMAIN EMERGENCY DOME UGHTS N , CONNECTED TO NURSE'S N Z PULL-CORD NURSE'S CALL SWITCHES ADJACENT �, J DEMOLISH PARTITION. / � CALL STATION. � TO TOILETS � a i W � REMOVE ALL PLASTER N AND LATH ALL BATHROOM .- � O WALL SURFACES & CEILING. STOR. � � � REMOVE PLUMBING FIXTURES. W = REMOVE FINISHED FLOOR. �yJ W U � ��^ C�ILING MOUNTED � � N O �� j � SPRINKLFR HEAD / N / CEILING MOUNTED LIGHT � (/') � O NEW WALL MOUNTED SINK A3 ` � m a � � / WITH ACCESSIBLE FLIPPER � T Y P E F A U C E T H A N D L E S WALL MOUNTED LIGHTING E p � Q 8 6 FIXTURE ABOVE MIRROR � � w Q D I � D A3 A3 . .. � 2"X2" NON-SLIP CERAMIC TILE '/ � � � � FLOOR THROUGHOUT (TYPICAL) w � _ � � o J N � NEW �OOR WITH 32" DR C7 EMERGENCY LIGHT LOCATED m � U� W �o A3 WITH CLEAR OPENING. NEW GROUND FAULT INTERUPT AT HEIGHT PER CODE � N ACCESSIBLE HARDWARE ELECTRICAL OUTLET 42" AFF � REVISIONS: � � � � � � � � � � � � � �� / % � / / %% / i ,/ , ,/ � , � � � � � q�_�^ EMERGENCY DOME LIGHT CONNECTED TO NURSE'S PAPER TOWEL CALL SWITCHES ADJACENT DISPENSER E TO BOTH TOILETS , EXISTING / DEMOLITION PLAN 2 PROPOSED FLOOR PLAN 3 ELECTRICAL PLAN PRo�Ecr NUMBER: nz ��2�� _, ��_0�� nz 1/2�� _ ��_��� nz 1�2�� = 1'-0" DATE: 2/1 1 1 /16 SCALE: i/2"=t'—a° DRAWN: PRL CHECK: ¢��`�QJ¢p esq��� � DRAWING NUMBER: * W . 9 � o LE y �o �s.� � � � � �5 c� � � q�TN OF MP`-'Sp ..__ . . . . ..._._,._-,.._ i . . .. ^- � � . ... .. . . . ' .. . . _-- .-.. '.. , , . ., .___... ..____ .____�__... _ _ __ _ _ _.�...,..__ _�_ � o � � � rn � \ r o O � � Q � VJ U � � � � � m = W Q W � Q � � J IMPORTANT NOTE: J o � Q EMERGENCY LIGHT NEW DOOR AND WINDOW SEE BROOKHOUSE ADMINISTRATOR w w w SET AT CODE COMPLIANT MOULDING TO MATCH EXISTING ■ � W LIGHT FIXTURE HEIGHT FOR "SUBWAY° STYLE WALL TILE /y� W � o ABOVE MIRROR T.B.D. COLOR AND SIZE. � � � � � LIGHT FIXTURE �� ABOVE MIRROR T.B.0. � � o J W N � a � � ^ . w °� � J 2 d : � � T GFI DUPLEX ELEC. OUTLET � \ ST. STL G�RAB BARS PULL—CORD � � W/ NON—SLIP SURFACE STATION � TYPICAL � � ) � � � 8 ;� I � � � � I I + EXISTING T�P� 0 RECESSEa m � °i , RADIATOR; � N a i•i o i N N I I jj i COVE BASE TILE (TYPICAL;) , BATHROOIM ELEVATION 2 BATHROOM ELEVATION 3 BATHROOM ELEVATION 4 BATHROOM ELEVATION � ''�,� A3 1�Zn = ��'�n A3 ��2n = 1�'�n . A3 1/2u _ 1i'On A3 1�2n = 1�'�n 1 • . � i � _ EMERGENCY LIGHT NEW DOOR AND WINDOW IMPORTANT NOTE: � SET AT CODE COMPLIANT � MOULDING TO MATCH EXISTING SEE BROOKHOUSE ADMINISTRATOR W ' HEIGHT FOR "SUBWAY" STYLE WALL TILE (n COLOR ANO SIZE. LIGHT FIXTURE � ABOVE MIRROR T.B.D. LIGHT FIXTURE w = ABOVE MIRROR T.B.D. �J W U � � Q cn PAPER TOWEL � �/1 (n � DISPENSER � � a > I m � � � w ST. STL GRAB BARS GFI DUPLEX \ PULL-CORD � Q � W/ NON-SLIP SURFACE ELEC. OUTLET � � \ STATION � p (TYPICAL) �\,� Q � J � \� � 00 Q '_ - � ' � � � (/i m .0 a ' ,�, a �o _ _ .__ _ _ � � REVISIONS: � ' - + � + o ( T.P - 0 b� � m I m � � '. i � i . i < I ' N N � p � � p N . . � N i N � N _ I I COVE BASE TILE (TYPICAL) � 5 BATHROOIM ELEVATION 6 BATHROOM ELEVATION ��THROOM ELEVATION � BATHROOM ELEVATION PRo�Ecr A3 1/2" = 1'-On . A3 1/2" = 1'-0�� n3 1/2" = 1'-0�� A3 1/2" = 1'-0" . N U M B ER: �, DATE: 2/1 1 1 /16 SCALE: i/z"=i'—o" , DRAWN: PRL � CHECK: � � R UA ` ����U pLES4�'S'r , a DRAWING NUMBER: ¢,N ¢ � * �.+.� 1JC�734 � o S��EA� �n � �y ass. � f� o a�� . � \�( �qtTliOFlAP`��'Pc � � , ,. U z � � c � q -7CB RECEIVED The Commonwealth o assac uses Department of PubtG�afgJy� ^ fin. �t WIY Massachusetts State Building E!tldbf CMR) Q W L h Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: _ Q SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ' No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2.PROPOSED WORK Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below _^ Existing Building❑ Repair VI, IAlteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) \W\ Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? / / P gir g e9 7 Yes ❑ No CVO Brief Description of Proposed Work: ,flz n`w c�,ye.. 6`iqrl#mil &. ez faj� . SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B. Business ❑ E Educational ❑ R Factory F-1❑ F2❑ I H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4 0 H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ 1 M. Mercantile❑ j R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6.CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IAA ❑ IIB ❑ MA ❑ 111130 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 11LO for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site O Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ I Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: pONDI M. Salem Historical Commission 120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ✓ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Derby Street Address of Property: 180 Derby Street Name of Record Owner: Brookhouse Home Description of Work Proposed: Replace missing slate to match existing. Replace copper valley flashing to match existing. Replace 10' of molding to match existing. No changes in color, material, design, location or outward appearance. Non-applicable due to being in- kind replacement. Dated: April 14, 2016 SALEM HISTORICAL COMMISSION By: & c 2 +�, The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. Once completed,please submit a photograph(s) of the final result (maximum offour-i.e. one photograph of each affected fagade). THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work. SECTION 9: PROPERTY OWNER AUTHORIZATION - Name anndpAddress of Property Owner // / S/ / a Name(Print) No.and Street City/Town Zip Prope,Ity Owner Contact Information:: lil Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes �u cf, Ch a. Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control 1 /0 Z y j ifGBG f f oF- �i n+r fjy 7k yr•Po /J U/97?9 Name(Re trant Tel,e.pphone No. e-mail address Registration Number y3 dTJzsv �c wa �j� �S rli n. 174 UlY1p /a /Y Street Address 6ty/Town State Zip Discipline Expiration Date 10.2nnGeneral Contractor / Company Name 'W C-"/'-77a9 Name of P/ejrrson Responsible ff�o+,rr Construction // License No. and Type if Applicable (3 may. 14 Street Address City/Town State Zip 8- 4 /�BK�' �/l 2 j3 yb£3li erf�ir.o,t,<1r04 - a ye"VVA , vr� 'Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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 Is a signed Affidavit submitted with this application? Yes❑ No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ u Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Q Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 1 O g. L 6.Total Cost $ �j �7s (contact municipality)and write check number here SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT 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 a best of my knowledge and understanding. Please print and sign n Title Telephone No. Date Ol�G2G Street Address City/Town +State Zip \ ' Municipal Inspector to fill out this section upon application approval: Name Date 4 The Cununontve.tlth of INiassachusetts / f Department of Public Safety A. �' \Ll�e,n lilts" s tihrti• IltnWml;cod"(:S0C.\lit) Ifuilding Permit Application for any Builtliog Ofher than a One_or'llvo-hamily Dwelling (Illis Set Lion For Official Use Only) Iluildinit Permit NOnlber _ Dale Applied: _____ ._. Building•Offit i:ll: _ tiECHON I: LOCH PION(Please indicate I)luck Y and Lut rY fur locations for which a street address is not available) l Ff pozeY..S`T54L—E Y1 fV\A- ©J 70 bfteIDAJS M�r►2 No. .md Barest City ;fuwn Zip Code 1 Namew ltuildinl((iF:lpplitdblc) SECI'(ON 1: PROPOSED WORK Gdiliun Of .\I:\Stilt'Cndc used . _ If.Vcw Cunstnit lion chctk here❑or chock all Ih,it I , , f f 15' in the Ilvu nncv bvluw li\isliug IAlilding Repair❑ Aleraliun Addilwit❑ Demolition ❑ (I'Ivow till oul and submit.\ppendi.x 1) Ch,nll;r ul C'se C'11,ulge of OccupaucY ❑ Other ❑ Specify:._ �1/"� -�`"f� \n•builJing phuls❑,Ind/,Ir coIIsl I.[IV Iion&k'u IIIVII Is bt'.illg Supplied as part of Ill is permit appIic,It it)n? 1 _ NOB 'Nu Cl Independent Stnldural &Igineel'II Peer Review required? Ycs ❑ Nu� iiricF Utwcri ,Lien of Proposed lVurk: .. (� � /.0^7.7 SECTION 3:COMI'LGFE THIS SL'CI-ION IF EXISTING BUILDING UNDERGOING RENOV,\TiON, ADDITION,Olt CH,\NCE IN USE OR OCCUPANCY Check pert'Co, Exiltillg Bttddillg Iltye9tigation and Evaluation is clicit,setl (See 7,41)C,\IR 4) ❑ E\isling Use Gruup(s): SEC I ION 4: BUILDING MIGHT AND.\REA - Existing Pn,poseJ No.ul Floors/Stories(include b.iscnlent levels)dr Area Per Floor(Sq. ft.) I'ut.d.\rea(Sq. ft')end rutal Height(ft.) SEC HON is USE GROUP(Check as a liatble) \: Assmnlbly:\-I ❑ A-_'❑ Nightclub ❑ :\.1 ❑ A.4 ❑ :1-i❑ B: Business ❑ F: Facto F•I ❑ 1:20 E: Educational ❑ 11: 111 h Fi.tt:vd fl•I ❑ if-_'❑ II-.l ❑ 11-�❑ I1•i❑ 1: Institutional I-1 ❑ I-1❑ 1-.I❑ bt❑ :\I: Mercantile❑ It: ItmslJuntial R-I❑ It•1❑ R.t❑ It-� ❑ .S: .Sturagr S•1 ❑ 5•?❑ U: L'lility❑ Special l:'se❑.Ind de.lsc dcxnbt'below: �pct ial Use S 6'Cr1ON :CONS rliucri ON LYPE(('heck as a) licablm) 1.\ 0 ilia II.\ ❑ IIB ❑ III,\ ❑ Ulu ❑ IV ❑ VA \'It ❑ SR FION is it E IVPOIi.\L11lON irder it)7,40 C,\IIt II l.1)for details on each itch) Water Supply: I flood Lune Information: .Selvage Oispu.aaf: french 1'ennit 1lcbris IAvll,v al: Publi I CL•v,k d:nn+Ids hLa'd Llano❑ InJitulc numit ipal� .\ tench tvdl not be I prnsrd Ihsl I�s,d�ih• ❑ I'm.nc 0 ,r lndvllnly A,,, _ :�r on .11c st.lcnl ❑ I'll,red ❑„or."1, :o .pruft- !`rnnll h rm nwd ❑ 1 RailnlaJ right-uf-,v.aY: Ilavards lu.\ir .\,nig,diun: \:•t A! !•h,.ddr❑ Laru,turn nllltw,ur rt.I r nit.Irr.l' !"' {'!' "• 1. Ihr lr Irciro :, nlldr h'd' :•r t' Inrut l,: IfuJd :n,6�.rJ ❑ I 1rvLj r \',:❑ 1r. Cl ❑ : tiFCll(1.V S: l O,VIF.V 1'nFI�L II rIPI('.\I'F UFl)( CL'I'.\.\'CY P It!•r q l• n•IIu,II: n t4: a{ ,un l :•.rJ lorlirrr I I lrr. Ihr 6iiJJinli,• nl,un\in `-pm Alrr tit.Teel' `•I:rt i.Il ' I { iI l,rtli n. si:( iioN ,): 1,1(()il lit I Y OWN I It �Xlj I llOI4 IL. I I.ON t,N Ov,tier Lip citv/ Name(Print) No—ind Street ["ort-I tY Ov,Ilor C"Illa,I e-Ilmd addressi I itte 1'etephone No (Ilosilless) r,-tephone Nil It applicable, the prepett), owner hort-bi-atilliortivi Street Address city/ r 11 1;tate Zip Name m�it,tit work authorized 11 - this 111"Illit I'll'ilication. to I �Ij the prt,pert,, owner's it-11,11f, ill .ill nialtvi-.4 wl'Ifit LtLb�� SECTION to:CONS'I-itUL7rI0N CONTROL(Please fill out Appendix 2) 11"t k"I'ler ComitructionCOMMI the"check here(3 and ski iiSection 11 to I Registered pruiesgionji Respomible for(*'instruction Control Registnition Number (liveistrant) 1'elephone No. Discipline r.\Viration Date ;taue Lip �Ilvvt Address city/ rown 10.2 General Contractor t QD I. I I ly , line-tv'11111.I N I Aksoox_ 15- AeTt-'F-'xce-q� "Molle of Person Responsible fur Construction License Nif. and Type if Applic-lbit! —Zk,,B-- (ligE state Zip ,;Ilect Atldr&is 2 City/'rotv _ � No. (Llusille'4) rVIV theme No. cullI vlv ,hone Irmail address SECI ION 11: lt, 11, \M I .\I 111 G.L.c. 152.j 25C(6)) %I and A tV,,rkvr5'Compensation Insurance Affidavit from the CIA lI UCparoVII9 of Industrial Accidents must ve submitted with this application. Failure it,provide this affidavit will result in the denial of I he issuance of the building permit. Is siglied Affidavit submitted with this aPPlicatiOn' yes X* No 13 SECTION IT CONSTRUCTION COSTS AND PERMIT FEE ltval Estimated Costs: (Labor end \Llterials) r,,tat construction Cost(from Item N - 1, Building Building Permit Fee 'Total Construction Cost x (hosed livre llectric'11 Appropriate municipal factor) Humbill)" Note: fee l. MMI'mikal (IIV.\C) SO4 i. \lcchanical (Other) I 1:11ct(ISV Ilk-,k jm.vatlle tit 0 (contact awalil leek i1wr here It total Glst S SECTION 111: - GNA I URC OF BUILDING I'El(% r r s,I I'll, t1i Itv vnwring M. nun N-low, I hereby attest tinder the pal jI,I j,eiv.dtivi of pvr1tiry HIM .111 Ot the ep the l"-st oI lv, k1w, Icily; 'Illkl toldcr.41.11i'l ing. r qM l,I it.I lion i,I r t I v-)I L t L I r.I t e I I- I OALS79LICY7oAJ V Itatc Mlle Irlc I'll"lle \k. t'l "?;1I n.t 9 Z) 6—SQU(P—C-- Die , VE—) OVY m tv 111,0060 1f,tt Wd"'s t1i'lle'tor to fill mit this sc ti 11 Ill"m li, me tIv tiw 10-9JA Or The l(fc;-,m"m'onwe*iiltfi"'O.i 'Massac�ti-setts-�'� Department of Pubf ic Safety M,1SS,1CI1USV I Is St.1tV BUi ILI Mg ' , "C1d V'­(781)C%I'R Building mit Application i0r-iny,Buildi' er�han-a One-) 11YQ-Fahiil�Pyeliing, �id ,. , (This Section For Official Use Only) Building Permit Number: Date Applied: ------�— I BifildingOfficiA. SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) '5f 0 7-',) --f3r 44 k 14co j e—, No and Street City/rown Zip Code Name of Building(if applicable) SECTION 2: PROPOSED WORK Rlition of MA State Code used -7NewIf New C011SIMC6011 check here 0 or clieck all that apply in the two rovLs below Existing; 11:5,,Ei11,H:ng�V' Ropair 0 1 Alteration Vj Addition 0 1 Demolition W;(Please fill out and submit Appendix 1) clianguA4JI.Lsc 0 1 Change uL04 :"cy 0 Other 13 Specify:-- Are building plans and/or construction documents being supplied as part of this permit application? Yes Er NoM -- Is an Independent Structural Engineering Peer Review r YQS& No M"o Brief Description of Proposed Work: R e�14 0 ozl�e Al 4)f to x/ 5f, AaA 4614 raCP 7-07 0A Aln-�t P!i SECTION 3:COMPLETE TEAS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) 0 Existing Use Group(s): PW 7� 1 Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(111CILICIL'basement levels)&Area Per Floor(sq. ft.) 3 17,160 3 —171—3P6a_ Total Area(sq. ft.)and Total Height(ft.) r - 125,75-01 1 Z317rO SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 13 A4 Cl A-5 0 1 B: Business 0 E: Educational 0 F: Factory F-1 Cl F2 13 1 H: High Hazard H-1 13 H-2 Cl 11-3 0 1-1-4 13 . \ 14-5 0 1: Institutional 1-1 13 1-2 0 1-3 0 14 0 1 NI: Mercantile 13 FR. Residential R-113 R-2 3?'" R-3 13 'R4 0 S: Storage S-1 13 S-20 U: Utility 13 Special Use 0 and please describe below: Special Use SECTION 6:CONSTRUCTION TYPE(glieck as applicable) IA 13 IB 1:1 1 IA 0 11H 0 1 IIIA M" IIIH 0 1 IV E3 I VA [3 VB I SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: ) French Permit'. Debris Removal: Public Municipal I/ Chtsk if outsideC 1:10011 Zone 0 ilIndicateSr. A trench wj�M not be Lii coxed Disposal Site 0 % r eor trench or Private 0 or indentifV Zon". ron site Sy stem 0 perinit is enclosed 0 Railroad right-of-way: flazards it) Air Navigation: tit 1 '111 NotAppitcoblex IsStructure within ,firport.1pproa,harva Is I livir roviv%v or Consent to Build enclosed 0 `tcs 0 or No ar Ycs 0 No 0 SECTION 8:CONFEN r OF uRriFicATE OF OCCUPANCY Fditwool Code: I-soUrimp(s) ...ir I)oc, II w I,ii i I L I ing con in la in u n S P ri it I,It-r!T,t"111 spc,ial I,t I p tj Lit ions: SECTION 9: PROPERTY OWN Fit AU'I'l IORIZATION Nanie,uxl Address of Property Uwner _gook 46V 52 _ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: P��� Vyty rra� , Adw���Y7g�744-ou9�8) -bq'7-- gs7, l'itfa Telephone No. (business) Telephone No. (cell) a-mail address !, If applicable, the property owner hereby authorizes -- Name - Street Address .�, ,City/Town State 'Lip I' to act on the mt eel 'owiier.'sbelialf, iri all matters relative lowrirk�auth&rized by,tltis buildin +ernti6a lication., SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) • 1f bit ildin g is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 ) 10.1 Registered Professional Responsible for Construction Control • r Name(Registrant) Telephone No. a-mail atidress Registration Number Street Address s City/Town State Zip Discipline Expiration Date 10.2 General Contractor 1 i ' • i . " z ' • - sy' by Company Name lki# z 5• 6r7T-t3VC0u1?-r Cyr D53 �V vNrESTei-& Name � of Person Responsible for Construction License No. and Type if Applicable �CaU1�� Y 1Y11 . x6) Street Address City/Town State Zip 9!7S1- 3�-0'77 $-9 71 ea o • co Al _ Tole thane No. business ' Tcle shone No. cell a-mail address SECTION 11: tvt (kAIN,_',5A_LION 1 V;_1JW N('F Al Fit nVl l M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted withthis lip In provide this affidavit will result in the denial of the issuance of the building permit. Is a si%ned';4ffidavit s,bn itted with this application? Yes 13 No O •' - J`• SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=$ I. Building O-W S 11 Building Permit Fee=Total Construction Cost s (Insert here ?. Electrical y�['t appropriate municipal factor)=5 3. Plumbing 5 Qz)Ord'D 4. Mechanical (HVAC) S Note: Minimum fee=S (contact municipality) 5. Mechanical they) S '�nelose check payable to b.Total Cost 5 3 , (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Ilv entering illy 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. ' Please print and sign name Title l"elephune No. Date Sheet Address Cih'/Town State Zip municipal Inspector to fill out.this section upon application approval: Nante Date kos S_ -PL-*M IdtiST-BE ffLf�.APPROVED BY T44E .►nP,WTp}.3 ,PFWR TD.A.PERM1T BEING GRANTED rs� CITY OF SALEM No. 201 -2.0 U \ y�:`� ��\ Date D N6 . Is Property Located In Location of the Historic District? Yes /!No_ Building e Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: P\S,soc- - fog- Owner's Namervz� Address & Phone Architect's Name A/0-�, to Address & Phone ) Mechanics Name Address & Phone A �Ln ,s o What is the purpose of building? h MUI,T- I Material of building? If a dwelling, or how many families? C R-b�o L--1--AT1 W,�-- Will building conform to law? Asbestos? �- Estimated cost Q?J U. City License k N A state License # 60 ASS 00 home Improvement Lic. I C K L 15 S ignat a of Applicant SIGNED UNDER THE PENALTY OF PERJURY D EnON-OF WORK TO BE DONE / �Z 5 . D MAIL PERMIT TO: h-,t,-Q I-1A . No. 2-0-7 - 7_op�\ APPLICATION FOR PERMIT TO LOCATION. PERMIT GRANTED APP VFD INSPECTOR F BUILDINGS r GY- 7© Deb wrre__� 1..J 20*4 obw b 1id10 0Y1w YL Na_ 1BPowML000dh :- b oaw waroa Awd . yak.No. PwmR Io: MILD POW APPLJCAIM POI! (Ck"wlMoMM applO � ��, � k. Sh Otl m Doaed, P�oK num po L OIR UMLY A OOI/UMV TO AVOW DELAYS M PROCUUM TO THE MINOR OF bU LDUM.7hq . uR 11 ftad hMrby appin for a pw" fo build a000iefhp b ft.foNWA" OWWa Nun» Adbaw t Phone _/ G `Do2b y S^ (�f Amhftol't Nam Adaw A Phone [ llddraoa A Phone J L -E gyp( PW LC- mww a a�pr �2�c K r aq,b►nor.r�r ka�lat �eur�q aatieiw a dA Aaawsn �.a.rtlaaM �wuan.a��w.ue... c� I�-- a AMOoft NEII�1AOe1 TWO PENALTY. 1� n=-- a OF 1MOII7 ELF DONE Olr poLim Coe U�'Pv�2rtw L (' c STre[Ji2 ' — _PUPLlcATA,)G MAL PHMET TO: 80NC o �/6 ��s �� 991 N N t I f tt I � 4zf i ` loli, 1,+ ` µr Ww. I ' +, ;: , z ,