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2 LYNDE ST - BUILDING INSPECTION (3) CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KINMERLEY URISCOLL MAYOR 120 WASHINGTON STREET+ SALEM,MASSACPIUSLITS 01970 \ TEL:978-745-9595+ FAX:978-740-9846 APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS IMPORTANT:Applicants must complete all items on this page SITE INFORMATION ,,',^,�d4' h Location Name ( lr _ SCa• C1 Pe—Building Property Address _1 n6-e �+ Located in: Conservatio(nArea Y Historic district APPLICATION DATE fI Z 7/y01 Use Groups (check one) Group Homes R3 R4_ Residential(3 or more Units) R2_ Type of improvement Residential(hotel/motel) RI _ (check one) Assembly(Theaters) Al New Building_ Assembly(restaurants&clubs) A2rA2nc_ Addition Assembly(churches) Al _ Alteration Business B_ Repair/Replacement_ Educational E 'Demolition_ Factory(moderate hazard) Fl_ Move/Relocate Factory(low hazard) F2_ Foundation Only High Hazard H Accessory Building_ Institutional(residential care) 11_ Institutional(incapacitated) 12_ Institutional(restrained) 13 Mercantile M Storage Sl_Moderate Hazard d` Storage S2_Low Hazard O OWNERSHIP INFORMATION(Please typeor Print C;/learly), I� OWNER Name �e-Jcz p f�U-I Address 1 HU 'VOLy gt Telephoneq1r �1 1 Signature 12 c9. ( L(�! DESCRIPTION OF WORK TO BE PERFORMED }C e,�► V2✓� 0n S4 W��� V1CtInP�/Q� 6,Y-G,U)\wl ,S . ESTIMATED CONSTRUCTION COST 1 o Dl- +)0 ------------------------------- 6/ � 3�)q -Z/q&41 CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIM ERLEY DRISCOLL MAYOR 120 WASHINGTON STREET +SALEM,MASSACHUSCITS 01970 TEL:978-745-9595♦ FAx:978-740-9846 CONTRACTOR INFORMATION Name JOS-42 caa,GO. Address 0 _ 2 V e K Telephone 101'I-90 — I q5 Construction Supervisor's Lic# kp QIP, Home Improvement Contractor# ARCHITECT/ENGINEER INFORMTION Name Y- U✓1 h Address-7 OoA rooziUel � lA `18a Telephone4vl'18-$ — O 3 Mass. Registration # 3 L41-3-3 j� 491091 PERMIT FEE CALCULATION Estimated Cost x $11/$1,000 +$5.00= 139•©0 COMMENTS The undersi n d applicant does hereattest that all information stated above is true to the best of my knowledge under the7enafti s of perjury Signed /a eo (owner) (agent) APPROVED BY: DATE APPROVED: CITY OF SALE:NI$ 2UNSSACHUSETTS • Bun DrNG DEP kRT\MNT • 130 W\sHLNGTON STREET,3'D FLoOR TEL (978) 745-9595 FAX(978) 740-9846 KIJIBERL.EY DRISCOLL MAYOR "11�tois,�s ST.PiERRe DIRECTOR OF PUBLIC PROPERTY/BUMDING COMWSSIONER Construction Debris Disposal Affidavit (required for all demolition and-renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in r (,nna'm�e o�f facility) (address of facility) t re of per rpi applicant dat dcbrisalTdx CITY OF S.UX21, N'LkSSACHL'SETTS • BUILDING DEPARTMENT 130 WASHINGTON STREET, Yo FLOOR 'IST.. (978) 745-9595 FAx(978) 7404846 KIJiBE I.EY DRISCOLL MAYOR Tl4oxits ST.PtERR6 DIRECTOR Of PUBLIC PROPERTY/Bui DING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name(Busim-s iOrganization/Individual). . Address: �. City/State/Zip: a�0{� �i Are ,o an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 9 _ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(hit[and/or part-time),* have hired the sub-contractors 2,❑ 1 am a sok proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their IO.Q Electrical repairs or additions 1❑ 1 am a homeowner doing all work right of exemption per MGL I I.1 Plumbing repairs or additions myself.[No workers'comp, o. 152,§1(4);and we have no 12.❑Roof repairs insurance required.)t employees.[No workers' 13 Q Other �Yl 1. comp.insurance required.] •Any applicant that chedts box#1 must also fin out the section below showing their workers'compensation policy infurmadon. t I larteuwpns who submit this affidavit indicating theyaro doing all work and in=hire outside contractors must submit a new affidavit indiadng such. =Contnxtom that cheek this box must anached an wditioned sheet showing the come of the sub-controctms and theft III n'comp.polity icadog such 1 am on employer that is providing workerscompenswien insurance jar my employees. Below is fhe pulley and fah site insurance C ��/Q `� /// l Insurance Company Name:. r� r-7 �%T/�Yl Policy#or Self-ins.Lie.#: �/(D`S / 69vQ�/ Expiration Date:/ Job Site Address: h 3t City/StatePLip: LF'/> 1 t / ,Q 1 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insuranc coverage verification. /do hereby rert>(y w+der fhe pa' ene r e ury that the infbrmatlat provided above is ue and meet > atter n Da Official ase arty. Do not write in this area,to be completed by city or town oJriuL City or Town: _,.- Permit/License# Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department 1.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other--______ Contact Person _ Phone# I ✓/ee 1°iasrvnzaozuiea�,(� a�✓�aaaauaetla Ak Board of Building Regulations and Standards Construction Supervisor License t License: CS 96067 Birthdate: 212/1976 Expiration: 2/2/2010 Tr# 96067 y Restriction: -00 JOSE GARCIA 33 FLORENCE AVENUE-#T REVERE,MA 02151 - Commissioner - r• REVISIONS BY CL) , LL u,o�4� {�; c c�►�tU' W4. 4+Ve � '- �r i- D--j o� pc;{;,� ---}-- �. > 1 I ( > h ILLL JF..; --- — It -7 ERH�R �4 j V� - —; t -1 { + : PkI '��}•. ; r<�i"- �('- CJ:.�. �...�..;._ F. I1 � '- .i...J � I�J��. V �; f.i� i ...a'� I � ^,./_�.l�ttj ( � '- t , �'., d =<I �t T � �"�i��'r-� � -..�'�"'�c-was ''•." yJ f t 1 cf ►��t ) ��J 1�t 2 a.tq I w 7 © ' „ r : " 1 t' U f� kr�l R1�4 kJ ite - lQv t y � --— ""<,,�;• r , � Y,,}t ,� �4�'4i�..t.{ 1c�J ��h> -'�- v ��b.�tkt.:� � I�/ �`�` }� ,�:.,,� �h U '-:; � L1._ ,� z Ko(l�" t•-i:.���^a� � ^ �'J�C #i ;�' �t'C�A`�t�k�:sL�" `� f.,.. F ,�rj;IJ'4v `f r,r�t-! �� lnlE AEoV;� f�E`Cv� p.►ir_: �N�FC�.�...b+.t.) � t - IL D- .2 a to :cv1 Ly' �— CT F?y. F.P'wEVLIi y� PLANS ARE APPRO °G VEDi L/1: _ ' - ,^ f, l lE, FJN — — ��__ _ r.,.F rPRDSE TIJN�`u, oa C.,..� ._. CC11UE. �- -i•'i s�f�TiM �Cy 't.L.t:-. llrJ�a I^ ��l��L K`L-P•K a' ! z ' OF Y F`� Gi n \L'k i {f�)!..J � ` DATE 1/{V l. ��l• (/'"{ NSCALE -._. �-tk'E �vrr�'���. ^ �/ �� ,��!• � � ,! ���wF ,.iM�.t 6��t pfi��u�-, L+�S:.��-t--, f> �C�'I/J�+,��� •'.! ZjtiS. % '�-Y' " � I). C�-'�.ltJC'� �'Yli �, >, �'. �.� � � DRAWN f ------- JOB 8 N-) O'}_"G W t-! i:�7�•.F �� SHEET . Of SHEETS sroeRon�e♦,we romnro ,aa� i REVISIONS BY ALL Ly kA +jP � �.jT-,,�!Tj- me,l+tc//J or Ct>CE i S St tL( SNaLI C [� t`T= F 0 �D I� i�-�A1 CC?'� (r. Avc c 0 A0 Cr- V)// �. N Q. C DUB` (c • 17A- .57. `v r - f?i ! �' f _ y NO•i Y 4 f>�._ '�l �•. _ _,f'L -G'-A L, � { ��j = J �{o0f.� V��'-��" , � � C 'moi _`�- rIN 'YJ�., L- r --► _- -� ul /�•`r` Y �� �j1 r' 1 j4r$r< 4-4t-004j4 - - 341 W kr<twp ��S't1� >1{IaSI � t6rvl �� l ��tc F ► 10;. ...y1�r ;; 11 J, orlwy woty r • t _ S AEcv C , .�,� Vill it I�t IV/ - --- �' � .. ; pv PH L___- L ►�G'N� tiU `RPrP" tn C)VA 55, F DATE � � ys�l G�+ wFr.� �� FFLfi , G� f/i6 � - /Y// 1 % ' F u _ r " �}� I SCALE - rc F?5 �j -- - ' )�rF DRAWN , U 1 -0 fYYYYJ rff6 1 [yG ,•� j� w �4i y srai Jos SHEET x i Of SHEETS STOCMORA.TING FORI.I MQ 10153