6 FAIRVIEW AVENUE - BUILDING JACKET CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
-_ 120 WASHINGTON STREET,3m FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
October 15, 2007
Thomas and Judy Moran
6 Fairview Ave
Salem Ma.01970
Dear Owners,
I apologise for taking so long to get back to you . The Inspection that I did at your property
occurred on August 21,2007. In the second floor bedroom facing the Ballfield, the plaster was
cracked along the ceiling and wall joint. It was obvious that it was a new damage because the
room had recently been painted. The cracks separated the new paint.,and there was no sign of
paint inside the joints. It is very likely the damage was caused by the vibrations you felt due to
the construction nearby.. If further info is needed, please contact me directly.
7.StTierre
Building Commissioner
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Dt \1a,sa husetp Slate Building fade. 'Sol SIR. 7"' editwn
\ Building Pertnll Application Tu (lnlslnlet. Reputr. IRctw\me l h ❑e illoli,h a t " 1ii1
(hle ttr fito-/.1urrr
�- I'hu .Sernon Vor OtFier l ,e Only ---- -_---
llutlJtng Pci n i Numh• --- _ .0 pp IeJ
I 11•at.Uwr ------ -�t--- -/� CJ
19ulJulg ['um nu, . x'rhrr n(ISuIIJm , U.uc - -
!� .SEC"1'[ON 1 Nrfl•: FORMA VION -
1.1 Prop \ddress: ,.�n 1.1 Assessors flop & F'urcc•I Numbers
lX� ------ ! - - - - - -
- � N„nihe,
; ! !.: (, thu .III .a eepteJ ou r. .si � - _- . nt \I p N1 ;her P.11-
1.3 Zeat,e htfurmation: ! L-4 Property Dimensio:-t
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Zone �: D >o ..__-I Lo. \i.at,y Ill— - Flow arc a
;.i Nad%ding Setbacks (ft)
Front Yard ddc 'rat., � r:a•:I
RcyuneJ F.i ,iJ_t.. K:yuu dJ
t L!) 1."atcr Supply: ()•4.G L 40, 054) Flood Zane Information: _-. i.8 SeNsage.l_lasposal System. ;
l L�onc Outside Flottd Zane'
;h;hlic Pn date ❑ Municipal
, ,oc Ju tcm ❑poaal st+ .�
! Check ti yes❑ --
j SECTION 2: PROPERTY OWNERSHIP'
l 2.i�t,w., r of Record: r 6 ��� Ug
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N.u,;. lot Ser�ice'
Telephone
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St C TION 3: DESCRIPTION OF PROPOSED WORK`';cheek al" that apply)
I
Nrw L n trt,ita• v O i . stinE Budding ! 0%,ncr Ue.up:e'' R�)t •v,�: J L U •;1 ,Iv �t.IJ n C;
t� '7etnoiht n IA,Ce,4oty 61Jg t7 ! Number of Un t (it her 0- SIt e,ty
-- - -- .. ..:.,_.
Urp�i ;ie. ' F: ton of Prupused 4b'.'rk` _ - ---'-_--- --.---____ —
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SECTION 4: ESTIMATED CONSTRUCTION COSTS --
Item f_,umated lust.: ffi
Official Uw Only
_--- Lahor .,nd ylawKIlSI I o
I. Building Perintt I ee. 3---- Indicate lu ass lee I, detcmmit d
I 13wIJmg ; ) /O�pv �I r
F-- ❑ Standard C1ty.Tuwn \ppheam In Ice
�b lo0- ❑ Tntal Project Coet' (item 0! a mule pi ier
IPl—um—htnp-- 'S '. Other Peen
1 �tecl 'h:mtcal 13i% A0
Slechan,, 0 IFirt --- "------ .. .
Su , ire+,1,,nt —._—
Check No l heek .AIn,natt: l'.nh \In•atnt
0 rolal Project Cost S /U — /2 IC ! 0 Paid ut F•.tll 0 f1u11I.in1b I1� BALM' I)ue
SECTION 5: C•ONSTRUC"LION SER%ICES --
15.1 Licensed C•mutruct ion SupervismrICSIJ '
SI l,pe l,ri hi lnw l
l l it,e,i n,led �u +to " IMIU( u 1:1
R Rcdn,IcJ L,._' f.muh U,1 citing _ _4
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falcphone \1—t-R:-IJcun.J \\mdo,,
it I Nc,IJcun.,lti,dlJl eI ISullon�\�I_u,._In_L,Ii.ILIi
�D K.•,;JcnlLd Uri nohll,.0
5.2 Registered Ilome Improvement Contractor IIIICI
tin'('on panm Name Ur III(' Reel,trant Nalne Reeulration Nulubcr
AJJres, - -.
F.a{ul anon Date ..
S,gnalu'e telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(N1.G.L. c. 152. § 2506)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. F.ulure to pn,s ide
this affidavit will result in the denial of the Issuance of the budding permit.
Signed Affidavit Attached? Yes ....... ❑ No __-. .. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1. _ U as Owner of the subject property hereby
authorize to act on my behalf, in all mazer s �.
relauve to wink author) by as building permit application. v -
S1 1lature, Owner Date _—
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent herchy declare
that the sr teme ns and information on the foregoing application are true and accurate, to the best of my.knowledge :Ind
behalf. -
I
Print Name - -
Slenutureot Owneror Authorized :\gent Date \ _
tit ried under the ams and penalties of (u l
NOTES:
1. An Owner who obtains a budding permit to Jo his/her own work, or an owner who lures ,ut unre�ntcied c,moa,Ian
(not registered in the Home Improvement Contractor (HICI Pmgraml, will not hose acces, to me .uhmauon j
program or guaranty fund under NI.G.L. c. IJ'_A. Other nnpOrtant inl„i maoon on the III(' Pn,ur:m\ .Ind
Construcoon Supervisor Licensing IC.SL)can he tuund In 7,40 CNIR Regulations I M.R6 and 1 10 R5. re,pccu,cl_a
When ,uhs(annal cork Is planned. provide the Intirmation below:
Total floors area 1 Sy. Ft.I nncluding garage. finished hasemenUattirn, decks or Iuuch,
1 firms Irvine JreJ ;Sq. Ft.1 H:IbltablC room count -----_-__-- ..
i Number of hrrplaces_ Number of hednunn,
Ntlniher „r halhnumis _ Numher,o h.,Ir;'balh,
Numher,JJe,k,/ pta,hc,
Ivpe „t .,.Ame ,s,mm---
3. A'oi. 1 Project SLILlare Ftiolage may be ,uh,tituled b❑ t;,LI Prnlect (•,„l --,-_
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PURCHASE ORDER
Fiscal Year 2008 Page 1
Ord r #e '00407357-00
WINER BROTHERS INC
P O BOX 590
86 LAFAYETTE STREET
SALEM, MA 01970
'�`-Vendor"Phone Numoe� "= Vendor.Fax Number �.Re'`:uisition Nu
978-744-0780 978-744-9386 00008214
abate Orderetl" ;.Vendor E,Number »Date Requireds 4&;F- Freigt
_ .
04/02/08- 005566 03/28/08
001 SUPPLIES. NEEDED FOR PUBLIC PROPERTY
DEPARTMENT
11922-5431 50.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I.\)�'K I': \C.,.I ii?:�;:,��S:I<I h ♦ S.N.II \I. \I it •i I
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\Norkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A l licant Information /J(�� Please Print Legibly
Name IlhliitlellOTganitamm.h ldlv �`//�'du:dl:� C. I- •`r-S`r� �
City stale zip: Phone d: 6 l7 — 6 &G — 92 573
.ire uu an employer:' Check the appropriate box: 'type of project(required):
I. I am a employer with 3 4. ❑ I um a general contractor and 1 6. ❑ N• ' construction
employees(full and/or part-time).* have hired the sub-contractU rs
P' 7. Remodeling
'.❑ I :un a sole pnrprieror or panner-
listed on the attached sheet.
,hip and have no employees These sub-contractors have S. Demolition
working for me in any capacity workers' comp. insurance. y, n Building addition
[No workers' rum insurance 5. ❑ We are a corporation and its [,��'E/
[��� P� 10. lectrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, $1(4), and we have no 12.0 Roof repairs
insurance required.] f employees. [No workers' 13.❑ Other
comp. insurance required.]
',\ay applicant that checks box NI must also till out the section below showing their workers'cumpensation policy infurtnatiun.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-Contractors Ihat.heck this box must attached an additional sheet showing the name of the sub-contractors and Iheir workers'comp.policy information.
/our an employer that is providing workers'compensation inssuranee for troy employees. Below is the policy and job site
in/brinr(tion.
Insurance Company Name:.
T
Policy #or Self-ins. Lic. #: h ` � CS -`el,qSQ`f Expiration Date:
Job Site Address: P G ifZV7`C.C.IJ — City/State/Zip: ,Sq,11'e6t yr( .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
failure to secure coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S I.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Incc.,riu;uions of the DIA I' insurance coverage verification.
/do hereby certj[I'o d e ad I, re.s o i¢}_that the injirrinvtion provided above is true rood correct
l I'1I LIItIr
Dale:
e: /3/G
1'1 toile
f lllicial use only. Do not write in this area, to be completed by city or town ofjiciaL
City or Town: _ _ _ _ Permit/License ------__----
Issuing; .iI mhority (circle one):
I. Board of Ilealth 2. Building Department 3. city/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ----------- _ -
Contact Person: —-. ----- Phone
Information and Instructions
\13SSJC IttlSCuS General I-aws chapter 1" regmrCs all employers to prox ide workers' compensation for their amplo}ees.
I'u r 5 na 111 tit this aawte, aft emplgree is do Il tied .0 ".. CN ery person in the se ry iCc of another under :my ek^act of hire,
cypress or implied. oral or wriucn."
.\n employer is defined as "an indl%ideal. parncrship, association, corporation or other legal entity. or any two or more
e,f the tinrgoing engaged in a joint enterprise, and including the legal representatives of a deceased cutployer, or the
rcccivcr Or trustee of an individual, partnership, association or other legal entity, employing employees. However the
ire tier of a-dwelling house hay ing not more than three apartments and who resides therein, or the occupant of the
dw tilling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the wounds or building appurtcnam thereto shall not because of such employ ment be deemed to be an employer."
\IGI_ chapter I i2, §250 h) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth.for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, %lCiL chapter 152, �25C17) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfia-mance Of public work until acceptable evidence of compliance with the insurance
rrquirentents of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone nnmber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding.the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rown Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom '(
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pernmulicense number which will be used as a reference number. In addition,an applicant-
that most submit multiple permit'license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under-Job Site Address' the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been Officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dOg license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I-he Otfice of Investigations would like to thank you in advance fix your cooperation and should you have any questions,
please do not hesitate tO give us a call.
the DQpartntcnt's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Ile%iscd `-_'b-Ili
www.mass.gov/dia
CITY OF SALEM
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� * ,,_ PUBLIC PROPRERTY
. v DEP AR"I'MENT
.V ,, •�; IJC Ur.!u� .., ��r?i.rr • >.v ut, \In"� . .: i , . _I•� :
Construction Debris Disposal Affidavit
(Iequiied lilr all demolition and renovation work)
In accordance \k ith the sixth edition of the State Building Code, 780 CM section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit if is issued with life condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of'in
nn (name of lacility)
. (addr"sot facilo.v)
vg iatnrc 'pcnnit.tpplicant
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Board of Building Regulations ;
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HOME IMPROVEMENT CONTRAC
Registration 154246
Expiration:' 2/20/2009 Tr# 254300
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"Type;' -DBA ..
GM CONTRACTORS AND ASSOCIATES
GREG MAITLAND ,
21 ROWLAND ST. � �
MARBLE HEAD, MA 0 1945
Administrator a"
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