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0019 CHESTNUT STREET - BUILDING JACKET KL; onwealth of Massachusetts CITY OF Siff ��'�g Aegulations and Standards SALEM � Massachusetts State Building Code,780 CMR Revised Mar 2011 Building�erdfit-AppFica&Jn o%struct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling ;.This Simon For toial;Usa Only .. wil Date APf�ed: e l�` y Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted streYes_ no Map Number Parcel Number et? 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public 13 Private❑ Check if yes❑ _ SEGTLON 2 p]tOPERTY'OWN ERSRIPt D21wnerrof Record: �ti `f 5'a/,t,^'t /44.4 ork do Name(Print) City,State,ZIP /ei U'Aesl~w 5t: i 9 7� 7J/4 (0 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of ProposedWorli?: o e0' aoJ-- F,ro^f 4 ` J QAd d 5 t / 05 - .n r c SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials 1.Building $ 1, Buik3tng Permit Fee:$ Indicate how fee is determined: Standard City/Town Application Fee 2.Electrical $ 13 Total Project Cost'(Item 6)x muthl'Her x 3.Plumbing $ 1 Other Fees; S 4.Mechanical (HVAC) $ List: 5.Mechanical (Five $ Total All Fees:$ Jression . o Check No. Cheek Amount: Cash Amount: tal Project Cost: $$r 0!P0. C3Pail in Full [IOutstanding Balance Due:" k-'z:Fp(Z( G " CAJ IUE: J 'D C-prJtr Lf2,, ' �/ 1 y 7'n ta,L----r-) co G .c . SECTION 5: CO NS7RtUMON SERVICES J tl- struction Supervisor License(CSL) �s i�� gt�z.��td�� -r/' k.� License Number Expiration Date SL Holder P - List CSL Type(see below) �telsrriptioa .eet - S4/t"1t, o!v? U Unrestricted(Buildings to 35 000 cu.8. /4" R Restricted)&2F - Dwelling City/Town,State,ZIP M Masonry RC RoutingCovering WS Window and Si . SF Solid Fuel Burning Appliances y7fr 2S-7� VAk;d-%. CVyof%-Z4n-r,t+ I Insdatioa hone Email address D Demolition stered Home Improvement Contractor(HIC) 1 SI i Z--J, 5.2 egf ! ,5 17 Tg. Ka 9 0 , 2Ale- HIC Registration Number Expiration Date HIC Company Name or TUC Registrant Name H/ $boPH f i /- No.and StreetEmail address Selewt 1Ll/1' ®/47U - y�-7yN'Zg 7rj Ci / wn State ZIP Tel hone SECTION 6;WORKERS" ?YON I»URANCE AFFIDAVIT(M.G.L c.152.§ 251 C(0) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu of the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTWN 7a:OWINRR AUM R17A ON TO 1IE COAPLETED ASN QSYNEIt'$ RCO OR )SrOR _t lN1Q PVMMT 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. s�err K;�l�u, Print Owner's Name(EI onic Signature) Date SECTION 7b:O@VNERr OR AUTHORIMD AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Au d Agent's Nkme(Electro c Signature) Date 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at wtivw.mass.gov(oca Information on the Construction Supervisor License can be found at MMM.mass.gov/d-s 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basemenVatties,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces,_ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CY7YOFS"A MASSAaRMT. BULOWDEPAXIMNT 120 Wi►e WXffSnWj3WFlDM 7�L7�3-9595. StI�ERiFYDtRTS�.L FA% 740.9M MAYCR ST.P Djiscrrat arrnBurcpool►r/mmmwamaasgcmot Construction Debris Dispos&Affydavit (required forall demolition and.renovation workj In acoordom with the sbA edition of the State Building Code, 760 CMR,Section 111.5 Debra, and the provisions of MGL oW,S54; Buildkw Permit fi is issued with the condition that the debris resultbng from this work shah be disposed of in a properly incensed waste deposit facility as defined by MGL c 111, S 15QA. The debris will be transported by.- (name y:(name o hauler) The debris will be disposed of in: Sg' XIA4 i)yrn125�v✓•. (name of facility) �// DSbad„� ,sr Sa/Pvrr, .ND4orq>� (address of facility) Signature of applicant Date Dln � i t Fejt Salem Hislof ieal Commission. 'Z1',NASHiNGM1,Sfr .A;WM.MASSACHU ETI iS O197u I3%Ft 6tu3G&; FAF,978,7,'i GGDa CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salam Historical Commission has determined that the proposed: ❑ Construction ❑ Moving © Reconstruction ❑ Afteiation ❑ Demolition ❑ Painting ❑ Sienu'e ❑ Other-work as described below will be appropriate to the preservation of said Historic District,as per the requirements set forth in the Historic District's Act(M.6 I,.Ch.40C)and the Salam Historic Districts Ordinance. District: McIntire District Address of Property. 19 0watRUt Street �antc of Record Owner:Nathalie P3innev Description of Work Proposed: Rcphucn.cpha6slongles vilh.standing sewn Copper on too ofenb.vportico. Dated September 3 2016 SALEM HISTORICAL.COMMISSION C 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 fiom the Inspector or s Buildlna,s(or anv other necessary permits or approvals)prior to commencing work. Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving D Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire District Address of Property: 19 Chestnut Street Name of Record Owner: Nathalie Binney Description of Work Proposed: Replace asphalt shingles with standing seam copper on roof of entry portico. Dated: September 8, 2016 SALEM HISTORICAL COMMISSION By: ca / PU� 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. The Commonwe*h ofM4opansew Deparhment oflridwWaAai idents I Congress&vret,SuiteltV Boston,M4 02114-2017 wwncrrwscgoy/dia W. J— Workers,Compensation Insurance Affidavit Builders/Contractors/Elechiclaos/Plumhers. TO BE FH"wnN THE PFRMnrnNIG AUIEORrIT. lleaM Iatormstior: Please Print I�blv Name(Basioess/mpeizatio vidnao: 2-B KM-v!4 L zj, -t/C Address: Y/ 0541f ne- Sl- S4be,v ) A4A City) tate/Zip,:. Se+lew., /ylQ epic, vel . Phone#: . 97�' 7ya1 - 2 8 7,S Are yee m empbW Clock the.apprepriote baa: ofProject . nips (regatr�: 1.01ame emyloyawe .amloyees(0 wxIbFw-tMw)••. . 7. QNewcoamucti_on 2.Olam gaols}aopeieloraDa�moahiyamdLas'ememploXgo"*o qs for mem 8: :[]Remodeling tayeepaetty.(No wutrn eat:fdaoaoee mpmedl 9: 0 Demtilitieu' 3.q!am a bomwavadit as wmk myself.thio wwkaa camp insmanmregmodl t 10 0 Batlding'eadi6 . 4.0lwn a bomeowrar and wig behkft cam■otms m caukd a1)wo&mmypmpmty. I wdl emre that all eomadma eidw haw wmkaR•wmpenmlim ias em are sole 11.0 Electrical repairs or additions swahao 12. Phmbmg"tepeueovaddih 5.01mo agmes]eonaodwaad IWehimd Not m*4*znaduo ILftd m thea"eddwA 1 ..• t•Roo .. These.m?i m bavemrloymmdhevewmkm'samp muo�i 3 . 6.0 We areacoryoredm�ia oIn hareeaeiciwddiekri&ofaemplimperMQ.a 14.00fller 1S4,i1(4),and we haoeaoemployeea:lNo work='boa*insw=6 re.40ied j' •Anyapplieimi met 'ba#1 mug a6oB11omthe aedfmhebwalWwlogtheirwmkela ampeaou�polieyto oam t Homeowms who su7®t dais Ifimi`h iu gtbey aredubs an work and&Own ou4idew amat xuw*.new affid"b&MM WA tContracttoie that cheek this bw mg aniched an tmnuabofawmbwnftW=and amte whedworno atimea hon hero . employees.Ifinesab-aga;h.P.�oBO!e®P7oYK4lb<!.'m.�laovide>>�-wurLeialeomp lmlityammla.-. :.- :... . . Iamwiewmwthat/e Provdduag*wAerr'Compawet*ninswvueovfor4empl . Belawischepolleydik siti. dnjormadan. insurance CompmyName Saety SAS. IRIIe P v Policy#or Self-ins.Lic.# Expiration Date: Job Site Address i 3 ecEIL-Ki U r . S (' City/StetelTip: S 120 X�- C 7 W l O Attach a copy of the workers'compensation policy declaration page(shovringtpe policy number and eaplrationdate). Fat7ure to secure coverage as required under MGL c. 152,§25A is a eaminal violation punishable by a fine up to$1,500.00 and/or one-year nnprise®®t,ae well es civil penalties in the fare daSTOP WORK ORDER and fine of uP to 3250.01)a day aphid the woletoi.A copy of this t tatCMCf1t troy be fciwe dad to the Office oflnvesdgad.of 9.9 DIA for inaamce coverage verification. I do hereby eeiYiIA, epaw Y andpeuaftks ofpedury that the informadon provided above is twee and aw it S+mat�• 1, /se0 Date: Phone# q4$" 7H��o7875 O�eiaJ ase only Do not write in this area,f1)be comph7ed by ary or town a Vldd City or Town* Permlialcense# ISanhrg Authority(circle me): I.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massacbuseus General Laws chapter 152 requires all employes to provide workers'compensation for them employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual;partnership,association,corporation or other heal entity,or any two or mare of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employe,or the receiver of trustee of in individual,partnership,association err other legal entity,employing employees. However the owner of a dwellmg house having not more than three apartments and who resides therein,or the occupant of file dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on The grounds or building appurtensm thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)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,MGL chapter 152,§25C(7)states"Neither the commonwean nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please 511 out the workers'conmpensation affidavit completely,by checlring the boxes that apply to your situation and,if necessary,supply,sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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 Depmtmmt 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 Departmerit at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lime. City or Town Officials Please be sure that the affidavit is complete and painted 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 peva t/ficense number which will be used as a reference number. In additiom,an applicant that mist submit multiple pearmMicense applications in any given yea,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 proofthat a valid affidavit is on file for future permits or Hcenses. A new affidavit must be filled out arch year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a d9g license or Vernal to bum leaves etc.)said person is NOT required to complete this affidavit The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Q'TYOFSALEK MASSA(T•"ET7. BEUZMDseAiMMn 120 VA9MCNICS"UNT,3Dit'.oaa i�.(g18)7�5-9995. PAN 740-NO $IA�BRIBYDL MAYOR 7tscY�ssST.P�ae Dnaum zaeru3ucpxammdBumu cauamgcmm Construction Debris Disposa/Affydavit (required forall demolition and,.renovition work) In accordance with the sbcth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40,S 54; Building Permit It Is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed " waste deposit fadlity as defined by MGL c 111,S 151. The debris will be transported by.- (name y:(name of hauler) The debris will be disposed of in: Ts- K,`� �yrnp5 ✓ (name of facility) yl ©Sbor„� St- salPH,, Nu10«>� (address of facility) Signature of applicant Date d � f MU T-8E f UE9-A+d0 APPROVED BY T44E .MWECTDR PWR TO A.PEMT$,SING GRANTED CITY OF SALEM cow No.�—/n� .• w �`� '�� ��\ Date y Is Property Located in Location of the Historic District? YeszNo_ Building /`l dt' /'�f r� Is Property Located in the Conservation Area? Yes_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Dec Shgd Pool, Repair/Replace, Other: _-<U FEY- � t 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: I Owner's Name �s .� +J� 4- /�/' Address & Phone c/ 'h�/� -51 62S ) % 4 6 Architect's Name Address & Phone ( 1 Mechanics Name �7 T, Address & Phone 0-/ ) rY� G )-Tc) What Is the purpose of building? Material of building? w v4 If a dwelling,for how many families? Will building conform to law? Asbestos? Estimated cost '`j City License# N " State Lice se # Lome Improvement Lic. L1rl 4 X Sigma ure of AA6,1icant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE -,9 MAIL PERMIT TO: ��� �� I l No. APPLICATION FOR PERMIT TO LOCATION / PERMIT GRANTED 2.0 APPRO �AAD INSPECTOR OF BUILDINGS ACOR ` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/26/2005 PRODUCER (781) 598-4300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cassidy Associates .Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Y 4 cY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 232 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Swampscott MA 01907- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:PENN AMERICA Hayes, Donald T Inc INSURER e:AIG 15 Oak Road INSURER C: INSURER D: Swampscott MA 01907-2120 INSURERE: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADUL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPEOFINSURANCE POLICY NUMBER DATE(MM/DDNY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY TO BE ISSUED 09/17/2005 09/17/2006 EACH OCCURRENCE $ 1,000,000'. X AMACOMMERCIAL GENERAL LIABILITY PREMISES Ea occurrrence $ 50,000, CLAIMS MADE FxI OCCUR / / / / MED EXP(Any one person) $ PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECOT LOG AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ ANY AUTO (Ea aeei lent) ALL OWNED AUTOS / / / / BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS / / / / BODILY INJURY $ NON-OWNED AUTOS (Per aWdent) PROPERTY DAMAGE (Per accident $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR F—ICI-AIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ Is B WORKERS COMPENSATION AND TO BE ISSUED 04/12/2005 04/12/2006 X I WCSTATU- OTH- EMPLOYERS LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) — (781) 596-0592 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT SWAMPSCOTT BUILDING DEPT. FAILURE TO DO 50 SHALL IMPOSE NO OB CATION OR LIABILITY OF ANY KIND UPON THE ATTN: MICHELLE INSURER,ITS G NTSO EPRESE TATIV IVE ACORD 25(2001108) ©ACORD CORPORATION 1988 q, INS025(01wyn ELECTRONIC LASER FORMS,INC.-(800)327- 45 Page 1 of 2 a� ---—-- ---- I lie ('ommo m%callh \d \Ia,_,alliltictl, -- — -- li )IR t lidded or liutfdiug Rculdaltons and Stalid.ird, \II `'I( II' \1 I I ) . \I:haacltn,Clts Slate iuilding ('ode. 7SII ('\IR. 7'4 cNanitm I \ 1311ildin Per Application To ('onsltuct. Repair. Ren )\Me Or I)CIIIA1,l) a O - t,r /1ui-l•�unilt /hrlhri� I l _ '� \ I is Srinon For Olfiiial t',r U:dv BwlJutg Perron N mh• _ _ Dale :\pphrd / G7 nu ddinp ('uinnn,.nniru n,l,r.ioi i:l Bwld n.I" U.lii SEC"I'ION I: SITE INFORM:\ PION I,1 Prooue.tv 1.?drvss: _ I I + .\,s",urs Map & Parcel \utu'ury -!7 _CS ICS( qJ I l.t is thi, .tit \lap .-unhe; P.ti:. l \u�.uha 1.3 Zt ning Information: I.1. rr•^ ,:riy !Ilrovn_%rvns: _ _-n;_Gmnci -- !'r,n>u,r >r___ I I•k :\rca r,y.IU 1.5 Building Setbacks (ft) . Fnmi \'ard Side Yards Rear Yard Rrywird Pnnided Required Provided Rcyuued Pin,ldCd 1 16 Water Supply: t.\f G L c. 40. §y1: 1.7 Flood Zone Information: 1.8 Sewage Disposal System: —� Zone: _ Outside Fltx)d Zone:' .Yt unto al ❑ On ,ue Ju to,al ,},trim Public ❑ Pnvate ❑ P I _ Check it SECTION ?: PROPERTY OWNERS HIP' 2.1 Owner'of Recor .\.ur.: t Prot) Address for Sers ice Sirn:lure Telephune — — SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply) — New Clmstrmnon ❑ Existing Building ❑ Owner-Oei upied }$' fcepatr.,is; i7 1I >her:umnl,t ❑ ! :\JJu�;�n ❑ _ _ Demolition f] I Aci esaory BIJg. ❑-- Number of Units Other ❑ Spraty I Rriet Descnpnon o'Proposer( Work --- -�s__ ---- -- ------ - -- - I SEC T€ON J: F..STINIATED CONSTRUCTION COSTS Item E,umuted Cosa: Official Use Only it.ah,it.md 1laien:ds) I Building ) /� t)OD + L 4. Building Permit Fee: $—_ Indicate h,:,s Ice i, deiei itimcJ. ❑ Standard City/Town Application Fee ❑ Total Pro)rct Cnsl I Item GI + multiplier 3 Plumhing _1 5 1 '. (Other Fees: i 1 \Iechamcal i11VA0 I ti i Lnc_ leharrical (File ups _urs,utni F"dal :\II Fees 1—_'h__—k t� v (heck No le, \munr _ l .,,n \ei.,tmt ❑ ai ut o Folal Project Cost ��)S Paid Full Paid in Full ❑1)ut.LtnJ�ng B_i!_:n,.e Ut__ SEC 1'IOY 5: CONSTRUCTION SER't ICES S.1 I.icensed Construction Super.isor IC'SL) r7-/ 195 . b3 �° \wuhir I.,pn.tlinn U.tl: `anti�d CSI. IhdJir '4'' Lnl St. 1\jA'nii hChlw 1 ------- --i t •a,t�t_iu. 1 x Lgi ted t lM.' F l,!.mu 1i `•Ilt_Iet-- l _ (] / — l77 -7 R L I R.,i&(It ul K I is (' , tin f:li plume \\S—r.112i•iJ,uti.il \1 nJ _u Jl I.ii '_.- _ il: R..iJ.nn.J 1" hJ I IiI IL ui n At Ll n_tn_i III a. 1) Ri"dinu.J UCnwhoon 5.2 Re stered IIom Improvement Cunt rue I IIICI Ii IC('mown Name or IIIC Regl,trint Name Rcgislratwn Numho X r l- ..t^� Ev matron Uate tiI ❑lure frkph�ne. SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT tM.G.L. c. 152. § 25061) Workers Cornpensation Insurance atidivit must be completed and ,ubmitted %%ith this application. Failure In pray ide this affidavit will result in the denial of the Issuance of the building permit. - Slgned Affidavit Attached'' Yes .......... No .. .. .. .. ❑ - SECTION 7a: OWNER AUTHORIZATIO TO BE CONIPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L as Owner of the subject property herby - :tuthonzr C"o I O "W-C1:- �.J�Sf -ri�Y! to act on my behalf. to all jimm-is i relaliv_ to woo k authorized by this building permit application. X Sienatuw ui Owner Date SECTION 7b: OW'NEW OR AUTHORIZED AGENT DECLARATION 1. '—�A, L T / C , as Owner or Authorized Agem hereby declare that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and I behalf. Pnn Stenat i (Owncr or Authorized Agent Date St med under the ams and enalties of r u 1 _ I NOTES: __{ 1. An Owner who obtams a budding permit to do his/her own work,or an, ner who hire, Jn unreg111CI CJ c,mtra, hit (not registered m the Home Imprioemenl Contrllctor I h11Ci Prugraml, will not ha%e ,lice,, to me alhitranon program or guaranty tund under NI.13 L. c. 11_1A. Other Important mf�umation on the HIC Progr:un .md C'onatruc(u)n Supervisor Licensing 1(.'SL)c,m he tound m 780('%IR Regulations I IOR6 and I IO Ri. re,p"[]%Cly ' When ,uhmannal work Is planned, pnrytde the mfiumanon below Total floors area ISy. Ft.I nnCluding garage. finished ha,ement/atnc,. JCCks or Unrrh� llrn,s hvm„ area ISy. Ft.1 Hahrtahle room Count \umber of meplares Ntunber of hcdro iiin, -- ... Nuntbet of h.ohnnans type of heating ,%,tens __..— _.-. Numher I4 JCik,% p1a1hC, - Iypeut ,dine 7- "1'01.d Pn,leCt Square Footage' maA he ,uh,tituted for "1­o1.I1 Project Co,f' CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT NIA)) 1K I_'� \t \,i it Xt liI 1.1 • l.\1 I. \l. \l.\��.V !II si t ..19-� I*I.1: 9-8-, 4;')S9; its F\S: 9-8-74:-1I84o Workers' Compensation Insurance Aftidasit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly `;Iln� t Bo;mcs t hganvauun.InJtw i.lu.d l:�CJ��� � �t�V� ��C City, State iZip:Ihlf 1, rv� IYSPhone #: /IS' 63 9 — 0677 tire you an employer:' Check the appropriate box: Type of project (required):._ .. 1 I am a employer with� 4. ❑ sin a 6. ❑I general contractor and 1 New construction .� _ employees(full and/or part-time).* have hired the sub-contractors 7. Remodeling '.❑ I .,In a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors Imve 8. ❑ Demolition wvorking for me in any capacity. workers' comp, insurance. q. ❑ Building addition [No workers cumP insurance' 5. ElWe are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work g exemption right of per MGL I L❑ Plumbing repairs or additions P myself. [No workers' comp. C. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.) f employees. [No workers 13.0 Other comp. insurance required.) ':\ny,applicant that checks box#1 must also till out the section below showing their wurkers'compensation policy information. 'I homeowners whu submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Comractors that check this hox nmst attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l am an employer that is providing workers'compensation insurance for troy employees. Below is the policy and job site information. cc lusurance Company Name:. �'�2 �oV�i✓x� �r,)J Policy #or Self-ins. Lie. #: C V%._ 3Ggq Z4�� Expiration Date: 03 r)3 E) IubSiteAddross: l�CJ��S'�1 ]T CityiState/Zip: �aih �ft 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 M(iL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and'or one-year imprisonment. as well as civil penalties in the firm of a STOP WORK ORDER and a fine of op to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of In\caiealiuns of the DIA for insurance coverage verification. l du hereby trader the pains and penalties of perjure that the injirrination provided above is tree and correct n:uura. r Date: Phone Uf/ic'ial rise only. Do not is-rite in this area, m be completed by city or ton•ro official its or Town: ___._—_-- Permit/License #--- ----_—.--- l.vuing Xulhorily (circle one): 1. Board of Ilealth 2. Building Department 3. Ciivifown Clerk 4. Electrical Inspector 5. Plumbing Inspector 0. Other --.-- — Contact Person: ---_- --__-. _ Phone #:--_ — --. Information and Instructions \Ias,ac husens General Laws chapter Ili' requites all amplo\ers to pro\ide workers' compensation tiff I lie ir emlployees. I'm Strain to this statute, in rmploYee is &lined as "._es ery person in the set%ice of another under an contract of liire," e\I,ress or implied. orator wril[cn... .\n enrploVer is defined as "an indis:dual. parmtcr,hip, association. corporation or other legal entity. or ;Ili) two or more of file foregoing engaged in a joint enterprise. and including the legal represcntatis es of a deceased employer. or the rccei�er or trustee of an individual, partnership, association or other legal entity, employ ing employees. f-Iowcver the owner of a :welling house has ing not more than three apartments and who resides therein, or the occupant of the dwallimz house of another who etnplovs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto ,hall not because of such employment be deemed to be an employer." \IGL chapter 1 52, ;25C((,) also ;rates That -every state or local licensing agency shalt 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, NfUL chapter 152, �250.71 states"Neither the conunonwrealth nor any of its political -subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants - Please till 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 number(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 Town 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 permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitilicense 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 Iown)." 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. The Otlice of Investigations would like to thank you in advance for.your cooperation and should you hare any questions, please do nut hesitate to give us a call the Dcparhmen['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 Ite�iced 5-_'b-U5 www.mass.gov/dia •'''" CITY OF SALEM PUBLIC PROPRERTY DEPAR"I''�1ENT .. ...I .,; 1_; U.r,iu�i..,,N S r:n.r r • $.�I ut. \L\.,v II v'8 'J i-! 'i78.'4:'64t) Construction Debris Disposal Affidavit (rcLluired ii)r all demolition and renovation work) In accordance \%ith the sixth edition of the Statc Building Code, 780 C'hlR section 1 11.5 Dcbris, and the provisions of vIGL c 40, S 54; Building Permit 4 is issued with the condition that the debris resulting from this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c 1 11, S 150A. The debris will be dansported by: CcRg tQQLAL' ems- y (name of hauler) - I he debris will be disposed of in (name of facility) l addrea of facililvl . _ aturc of permit aP1 icant ,laic — �r lAtST BEfiLfP f APPROVED BY T44E .u -5PFXTDR PF1lDR TO.A.PERMIT BEING GRANTED CITY OF SALEM No.Ll4—ZOO`-( .`� .' .,q �.. Date O Z� \yam NEo�j° Is Property Located In Location of the Historic District? Yes No_ Building 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/Replac , er: 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: o��l Owner's Name Address & Phone ��/ �_(� ( 117t 21"y Architect's Name Address & Phone Mechanics Name �/ ` t�i�✓�� r� i •�K Address & Phone (F Sys c�81 Sy - z C 30 What is the purpose of building? / aLu ✓1 Material of building? (�C�y( /� If a dwelling, for how many families? Will building conform to law? Asbestos? Estimated cost /Z,010•w City License # N A State License # a qy7 Sal $'7 7"Ct, -7foS 2 Borne improvement ,/ Lic. / Z 0 Signature of plicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE lv l 1� ,Zfa o 0zrrk";l MAIL PERMIT TO: 6-1 vs-Ft • V,jbsv - cAm�L1Pa�c� ( Nr-'c No. 21 L -2-00L4 APPLICATION FOR PERMIT TO LOCATION ( ��� PERMIT GRANTED /0 2. APIShOVD INSPECT OF BUILDINGS —� fammanwra6k of 111a6eack"deffi 6 JtParbaasnl o f�G �f—/7tcidAFdJ 600 ewym{tiapimSi st James J.Camooes Uoslon, //Ias�r +•W 02111 Cu.'mrssaoaa Workers' Compensation Insurance Affidavit with.a principal place of business at: tta4iaottia4) do hereby certify under the pains and penalties of Perjury. that: O I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Policy Number 1 am a sole proprietor and have no one working for me in any capacity. () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. • i Ynoe=no t"t a coot'of llsis staeernent wis be foMaroto w the OfrKt of 1s dgaoons of the DIA Ior co+arage•etWK360a asso'M blest a SK"t co eragt as ttwwro unotr Section 2SA of HCL 15 2 can lean to the:noostdon of crkrinar otnanks conusdnt of a fsnt of w tQ4 I.50000 M WGr Oft yeari ira whhh rat,.esa as chi oe uWts in the Joann of a STOP W ORK ORDER ano a 6"of S 100.00 a,Gay at"rat m. Signed this j C /l o �` day of S" Deparcn+ent Liccn to/Ftrrrlittee building s Licensing board Selectmens Office Health Department _` VEnir C-`.rEPc,01E iNFCRi ;A iCN CALL: i7.727-=90C 40c -04, 775 co OF SAL,M. MASSACHU5ETT5 PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR 3 SALEM,MA 01970 TEL. (978)745-9595 EXT.380 �grina FAX (976) 740-9846 . STANLEY J. USOVICZ, JR. - MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition of Building Permit# all debris resulting from the construction activity b this Building Permit shall be disposed of in a properly license d solid-waste governedy g disposal facility,as defined by MGL c III,,SSI50A. The debris will be disposed of at: Location of Facility Signature of Permit licant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit rAp- lp c "'1 I t t dl, tCta1l� Firm Name,if any (S v Sri Vfg /X alSo7 Address, City & State The above statute requires that debris from the demolition,renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIll, S 150A, and the building permits or licenses are to indicate the location of the facility. iaL�lMffi -OE ftLf�APPROVED BY T*IE l.US.PEXTDR ,PRWR TD;A.PERMIT.B,EWG GRANTED CITY OF SALEM pNU i' No. 2 Z 5-ZOO Date z r U Is Property Located in Location of l// the Historic District? Yes No Building �9 4k4100`- Is Property Located in the Conservation Area? Yes_Nov BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Ro stall Si ' , Construct Deck, Shed, Pool, epair/Replace, ther: 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: �7 Owner's Name ✓ U'gaWr. Address & Phone �9 04At� _sIf (97Y) ZYY 62�> Architect's Name / u� Address & Phone (7r'( ) S9 P L�J d Mechanics Name 40 AA � Address & Phone &S 0', l Saws (7,Y/ ) UL LS?o What is the purpose of building? Material of building? L l Q 1) -4 If a dwelling, for how many families? Will building conform to law? t/44 Asbestos? AX Estimated cost �� OW, U city License# N A State License # 6 97 r9 G p0 Home Improvement Q I Glr. Lic. i 1 z r P17 X Signature of Appli nt 76,111 SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE L ', MAILPERMITTO: I I WAtr t'4cI Tof— wc . a No. ZZ5- Z� O� APPLICATION FOR PERMIT TO LOCATION, PERMIT GRANTED /S/l3 2. APP VFD . � • INSPECTOR OF BUILDINGS f PUBLIC RiOPER.''rY DEPARTMENT • • 120 WASHINGTON STREET, 3RD FLOOR SALEM,MA 01970 TEL. (978)745-9595 EXT.380 FAX (976) 740-9846 . BTANLEY J. USOVICZ, JR- MAYOR DISPOSAL OF DEBRIS AFFIDAVrr a that as a condition I ac}mowled In accordance with the provisions of MGL c 40,S34, 8 of Building Permit# all debris resulting from the construction tY governed by this Building Permit shall be disposed of in a properly licensed solid-waft disposal facility,as defined by MGL c III,`S/150AA..J The debris will be disposed of at i Location of Facrhty Si^gnamre of Pe 't Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) ��� Name of Permit Applicant Firm Name,if any f Address, City &State The above statute requires that debris from the demolition,renovation.,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. Corn.rlwnwa 4ahk 0/MWiaChw6f6 1J,pa.lmart� a/9,d�I,inf.,"«i" jatnes J.Camood Oaten, ///aa,aduwW 021 It Corrmsstoner 1 Workers' Compensation Insurance AffldrAt . . with.a principal place of business at: . . loarrse+r.rslaa do hereby certify under the pains and penalties of perjury, that: () 1 am an empioyer providing workers' compensation coverage for my employees working on this job. AX6— AMC llzy Ylz- insurance Company Policy dumber 1 am a sole proprietor and have no one working for me in any capacity Q 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: 541t.e Contractor Insurance Company/Policy Number Contractor Insurance ComPatty/Policy Number Contractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. I Vnot na cut a copy a(this atatemMt'g be foM1 aroed to the ORrct of invesritavons of the DIA Ix coverage wIt Wadve ano"laatrre to secure coveragr as reoaeta under Section 2SA of MGL 152 cm lead to the irwontion of cnri;u as otnxfm eonastint of a fat of w$041-SM400 MWor ont - yeart•ir.wwn t x ,ea as civi "wisin it the icwr at a STOP WORK ORDER ana a fine of S 100.00 a eM atirot mt. Signed this . T-Vts�j r:4/1,day of I �3 Lictnsce/Fcrmitttt: building Depamrment Licensing board Seitamens Office Health Department c r: GVtKiv"t iNFO „ .._, iON CL Li. _ i -- _ =. 400 X4C= , 404, 50�, SO°, �75 04/15/2003 09:45 FAX 781 599 1530 CASSIDY ASSOCIATES-- - - I®001: AC D. CERTIFICATE OF LIABILITY IN$UI�ANGE . , PRODUpER IRIS.CERTIFICATE IS ISS)ED AS A. MATTER OF INFORMATION CASBWY ASSOCIATES INS AGENCY ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE 234 HUMPHREY STREET HOLOER._.THIS CERTIRCATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES .BELOW. SWAMPSCOTT, MA 01907.2513 INSURERS ,AFFORDING COVERAGE 781-6904300 ISMNED wsuw A:COMMERCE INWRAI4CE COMPANY DONALD T.HAYES CO. INC. 15 OAK ROAD !Nwm°:PILGRIM INSURANCE COMPANY SWAMPSCOTT, MASS. 01907-2120 INsuRER C:GRANITE STATE INSURANCE COMPANY IIaSIrRER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TEAM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTTH RESPECT TO WHICH TIIIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE'UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rK TYPE OF INBIIRANCE POLMY NUMBER pmmw 1,01113 A oRDFAAL uAmury - WT2714 GEM= 0212114 EACH OCOURRENOE f 1,00D,000 X COMMENCIAL OWSIAL LIABILrry FlRE DMA40E W7 ene firo) 9 50,000 X CIAMIS MADE ❑X OCCUR MED FJw AAP w,Nurl f SOW PERSONAL&ADV INJURY a 1 OENBVL A&MOATE s 2,000ODO DENT AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPATP TIRO I 2,000,000 X POUCY f7 11 LOC B AUTOMOBILE LIABUM PMC.712UN Ovl2ios 02n2m COMBINED SNOLE LMIr ANY AUTO (EA eAtldeeB ALL OWN®AVMS BODILY IIALIRY I X SOMMLED MRCS (Per ABrmN X HREO AUTOS BODILY INJURY X NCMONNED AUTOS (Per 2CCW 1Q f PROPERY DAMAGE f OW ewUenl) OAUAOE UABOtrY AUTO ONLY.EA ACCIDENT s ANY AUTO - OTHER THAN PA ACC f AUTO ONLY: AOO f I=M LIABOJTY EACH OCCURRENCE s OCCUR El ot"ES LADE _ AGGMGATE s a OEDUCnBE s RenXRDN 5 E C wwxmo DOMMMAT AND WC.9B9.0B.242 02MZW OM2M4 X wC)�ATu• D EN ENINJOYM UABBIIV E.L EACH ACCIDENT a 100,009 EL DW-k%-FA BOWYEE S 7 EL DISEASE-POLICY LIMIT S SW OTNEt OU NPROM OF OPNUTIONGLOCATKMSM IICLIWE CLLt DNS:AODE°BY EN0031IE1MTPSPWAL PROVISIONS CERTIFICATE HOLDER AOOOENAL INS1Rm;,INSURER wrrEB: CANCELLATION TGWU OP SWAMPSCOTT, BUILDING INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBE POLICIES BE CANCELLED DEONE THE EtOPATgM 22 MONUMENT AVENUE DAYS THR RF F,THE MUING DISA M WILL ENDEAVOR TO MALL SO NAYS wRITrEI NOTICE TO THE CERTWCATE HOLDEN I?AMEO TO THE IFFY,BUT FALURE TO DO BO SHALL SWAMPSCOTT, MA 01907 NMweE NO ORRARAnD11 OR uAeBRY OF ANY IONO UPON THE RNSURET,NB AREIITS OR FAX N (781).53664590 RE+RPBENT'ATNIB. RIVE ACORD 25-8 (7197) ION 1988 The Commonwcalth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR. 7"edition BwIJt�p ` Building Permit Application To Construct. Repair, Renovate Or Demolishla okumodwo One- or Tito-Funrrh Duelling This Section r OfrKAJ Wse Only Building Permit Num a Signature: 3 D Building Commissioner/Inct peor o Biuldin Date SECTION 1 J Sif E INFORMATION 1.1 Prop�rTy�rJdre C` 1.2 Assessors Map 6 Parcel Numbers I.l a Is this an acce led street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(A) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G. c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal D On site disposal system D Public❑ Privarc D D Do Y❑ — Check if s SECTION 2: PROPERTY OWNERSHIP' rSignalure Owner'o, f,Reeor,¢: s�- l(/ d7i,�if'C e(Prigs), � Addrepss for Servin/J� Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of UnitsI Other O Specify: Brief Description f Proposed Work'• G. T -?C) SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building f ,f'dU�" 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2 Electrical S D Total Project Cost'(Item 6)x multiplier x J Plumbing S 2. Other Fees: S /' f 4. Mechanical (HVAC) S List: S Mechanical (Fire S 7oul All Fees: S Su ression Check �o. _Check Amount: Cash Amount: 6 Total Project Cost: S �� ❑ Paid in Full O Outstanding Balance Due: P A �r V� { SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) I " ) /N,yoe of CSLHplJer � SL i r l " ype I,cc below) Address , _ Unrestricted u io 35.000 Cu. Ft.�' Restricted l k2 Famil Dwellrn Mastinry Only RC Resrdenual Roofing Covering Telephone w5 Resident al Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regls)M mir rovverpj�cut Contractor(HIC) JZA Srd ? HIC Com 1pany Name or HIC Rigisuam Name Registrati / on Number AdAddresssf d � 79 /id /o ir TervZl w E pinti nDate Signatara Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE, FFIDAVIT(M.G.L e. 152.f 23C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes.......... 9� No........... O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 N l as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this OilAing permit application. - rbehal"51t,-', ature ofi news'r Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION D , a Ow or Authorized Ag t hereby declare the statements and informs on on the foregoing application are true and r&1444 t e est of my knowledge and i� NameT I J /Qture of Owner or Authorized Agent Date /d under the pains and penalties ofperjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will gg have access to the arbitration program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110 RS,respectively. 2. when substantial work is planned.provide the information below: Tool floors area ISq. FL) Iincluding garage, finished basement(altics,decks or porch) Gross living area(Sq. Ft.) Habitable room count ,~'umber of fireplaces Number of bedrooms Number of bathrooms Number of halfbaihs Type of heating system Number of decks/ porches Typeof cooling cystem Enclo,ed Open 1 "Total Project Square Footage"may he,uh,timted for-'Total Pro)cct Cost" CITY OF S.UX. NIs ANSSACHL:SETTS BUILDING DEPART.%1JUNT I'_0 WASHINGTON STREET, Yo FLOOR TEL (978) 745-9595 Rim(978) 744984 ICI.,BERLFY DRlSCOLL T Hows ST.PIERRs MAYOl< DIRECTOR OF PL gLIC PROPERTY/gl'QDING CO>MRSSION F1 Workers' Compensation Insurance Ailldavit: Builders/Contractors/Electr(cianslPlumbers i lleant Information / PI PrintLegibly N2lnC (dusinns.OrWir&tionlwhv,dual): tiv�{ Address: �� ��dA-L (24 City/State/Zip, J 't!:vg ftir� Phone p '7 S fr ZA-36 Are y u to employer'Cheek the appropriate box: Type of project(required): I. I am a employer with Z 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or put-time).• have hired the sub-con racmr 2.❑ 1 an a sole proprietor or partner- listed on the attached sheer. i 7. 0 Remodeling .hip and have no employees These sub-contractors have B. 0 Demolition working rar me in any capacity. worker'comp.inaufatrm 9. 0 Building addition [No worker'comp. insurance S. 0 We ate a corporation and its 10.❑Electrical repair additions required.) officers have exercised then ).0 I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing mpain or additions myself.[Na workers'comp. C. 152.41(4),and we have no 12.0 Roof repairs insurance required)t employees. two worker' 13.0 Other comp, insurance mquired.j -Any applicant tier checaa boa el MUSS also fill UW tlw Yctien below sbawing itself worket'cpnimo g o Polity it iffmanoe, 'I I.rrwuwtitae who submit this affidavit indicting they am doing ail work aia then him otmide contractors Must whink a new amd,,it indi niiit suet T.Mimiare dial cheek ibis ben Mine anwhd an slditiun d dissa showing do rare ornf aub.eoMrnerws yid their worksm'tyres.Pdicy i,tannosten. f one an employer that bOrovidfng worker'compasmtfon lnsarancefor my employees edaw fs the pe/ley and JO&sfse informal" Insurance Company Name: ✓2✓A�+...� rrI raw .�l Policy N or Self-ins. Lie. N:_ W//� ( Q-7II__r2 R y7 Expiration Date: !7L /S [o Job Site Address: I o) ( d..� Sd City/StatdZip: ��b�/_ attack a copy of the workers'compensation policy declaration pap(showing the policy number and explradon date). Failure to secur coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to S250.00 u day againsl the violator. lk advircvt that a copy of this statement may be rurwarded to the OIYce of I nvcbngaiiuns orilia DIA for insurance coverage verification. 1,16 hereby,certify under t �,hapeins and penaties ojper/ury that the h1formalloe provided ubove is true and carreea Phone s: 197 O/J7ria/use on/y. no nor write in this area, to be.amp/erd by airy err town o/fkiaL i Ciry or ream: Permit/I.lcense i Issuing.'suthorily (circle une): — I. Iluard of Ileallh 2. Auilding 0eparlment J. city/rown Clerk J. Electrical Inspector 5. Plumbing Impeetor 6.Olher C wifact Person:. _ ._. Phone N: - ,S CITY OF SALEM PUBLIC PROPRERTY a T' DEPARTMENT ll .1.-n IBC W.w11.\L S.\I I'M. }1.\,i.\l I FI: '/7B-74 9395 • 1°.\Y:978-740-'/846 Construction Debris Disposal Affidavit (raµtired fur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CIVIR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tl is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transportcd by: �--- tna of haular) File debris will be disposed of in f4 h,ameur�a'ci Ityj (address or racilay) 41 ,iguatu�f) nlTapplicant l/ /ZULcJ J tar kin i.�l[L,r 091114/2009 16;03 FAX 19787779280 CASSIDY ASSOC D1001;001 CERTIFICATE OF LIABILITY INSURANCE DATEIRMRTDYYYTI 9/14/aoc9 PRoaUMR (781)598-4300 SAX: (781)599-1330 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cassidy Associates Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 232 Humphrey Street ALTER THE COVERAGE AFFORDED V THE POLICIES SELOW. I Swampscott KA 01907 _!INSURERS AFFORDING COVERAGE NAIC# MOORED INSURER!-VermOTlt WtU81 126018^' DONALD T HAYE3 INC NSURER e;PiltJr;I,& Insurance Company _ 15 OAK Si INSUM C-Granita State 19WAMPSCQTT MA 01907.2120 I INSURER E: ES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 9UgIECTTC ALL THE TERM:,EXCLUSIONS AND CONDITIONS OFSLICH POLICES.AGGREGATE YLlMITS SHONM MAY HAVE SEEN REDUCED BY PAID ON�L�MSsm 4- �,CN occuR � I s 1,004 4, 0-O -I IS 09204 TYPE of NeUttBNCF_ POUCY.NUMtlER. UNCM GE TO E FX COMMEUI JAL G r ENERAL LLASILTIY PN 18ES(Et ccaunaTce S 50�000 A CLAWS MADE jx OCCUR BE7.0003583 7/13/2009 7/13/2010 LARD,E%P iAM era Qemwl '6__ 5,000I, PER90NlLI kAOV INJVR4 _-„1,000,GOD RP r �LUC i PRODUCTS AGGREGATE _l5 _ �_OOCi� r PCTS-COMPIOP A ,GG S 2,000,000 - �OENLAGGRE ,TE LIRT APPLIED PEA: 1 ,K POLICY' is o. __. —T— AUTOMOelLELIABIUTI' I MM51INED SINGLE UNIT I I �Eaazasin $ 500,001 ANY a..rrD AL ohHEO A.UTOD iPGc10007129432 2/12/2009 !2/12/2010 e001LYINJURY iTr PageC1 E ^_ HIREO AUTOS I BODILY INJURY I g 'NON OWNED AUTOS i (Pr emitlun) L_ .I {(Peer tcceIY&0Aiv1AGE OARAGELIABILTTT — I 1AUTO ONLY-EA ACCAGNT 18 _.. I iANY AUTO 01T+ER TRCN EA AC_ C,IS _ I I I AUTO ONLY. I ExGS66tUNI1REL7-BIUTv •EACH OCCURRENCE S _ I ._.i OCIAIR j_i CLAIMS mwe i AGGREGATE ..... S I OEDUCTIILE - R N710N S E YJORKERb COMPENSATION WC STATU- OTH- C AND BNPLOVERSI LIA86R.Y - YIN Mi1S�.. ANY PROPRIETOPPAATNERVYE.:UTIVE I^I 1 'E.L EACH AOZIOETJT 'S _ 100,000 O°FICERMEMBER E%OLUO'eDT -- 1NaMa/vy�nNN) WI i5/19/2009 15/19!2010 'G�aSE-Eq 6HPLOY J _ 100,000 S�6I0.�PROJi9lON5 Dabw __ ,�_ ! ._I i E.L.DISEASE•POLICY LFNi' S 500,000 I OPNER I I I i I I I OEGCPJP'DON OF OPEMTIONE V LOCA?IONS 1 VE WCU58'Ex<P.U8IONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION _ SNOJLD ANY OFTHE ABOVE 0E8ONBEO POLICIES BE CANCELLED BEFORE THE E%PIRA DON Proof OE Insura oce OATS TNEREOP,TIE ISSUING INSURER TVILL ENDEAVOR TO NAIL 10_ DAYS ARITTEN NODOE TO THE GERDN)ATE NOIAER NAMED TO THE LEFT,EDT FMLORE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AOENI S OR REPRESENTATIVES, ' RRED RFPREBENTATN6 ACORD 25(2009101) C 1 V18.20U ACORD CORPORATION. All rights reserved. INS025owx1; The ACORD name and Ingo ,G registered marks of ACORD Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978) 740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction -A Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property- 19 Chestnut Street Name of Record Owner: Natalie Binney Description of Work Proposed: Replace twelve thirdfloor windows with 9 lite Marvin wood ultimate windows with bronze spacers, painted white to match existing. Ten windows to be cantilevered inward at 7"from the top. Two windows (one on each side of the house) to be inward swinging windows for egress. If available, window surround should be flush (without rabbit). Dated: November 19, 2009 C ALEEM�HISTORICAL LCCOMMISSION 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. The Cummonwcalth of Massachuscns Town of \ Board of Building Regulations and Standards lionow I � Massachusetts Slate Building Code, 780 CNIR, 7"edition Building Dept Building Permit Application To Construct, Repair:Renovate Or Demolish a One. or Tiso-Fanuls Divelling This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commission' i Inspector of Bwldmds Due SECTION 1:SITE INFORMATION 1.1 Property 1d�e `� 1.2 Assessors Map Ai Parcel Numbers I.is Is this an acce led street:'yes "" no Map Number Parcel Number I.J Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use La Arn(sq 0) Frontage(R) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Dbposal System: Public O Private O Zone: _ Outside Flood Zone? Municipal O on site disposal system O Check if s0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownerl of Record: q a A001HIS7 Servi ce: yy 6 9LT { Signature Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek ad that apply) New Construction O Existing Building O 1 Owner-Occupied O 1 Repairs(s) Alleration(s) O Addition O Derrtolition O Accessory Bldg.O Number of Units_ Other O Speciry: Brief Descnpti n of Proposed Work': r SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costa: Ofllclal Use Only Item Labor and Materials 1. Building 1. Building Permit Fee: f Indicate how fee is determined: O Standard CiryrTown Application Fee 2 Electrical f w O Total Project Cost'(Item 6)x multiplier a J Plumbing f 2. Other Fees: S. a. Mechanical IHVAC) f ,y List: i Mechanical (Fire S Total All Fees: f Su ession Check No. _Check Amount: Cash Amount:_ n Total Project Cosh f g1A1 W ❑ Pad in Full ❑Outstanding Balance Due 5- 4 .. SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed ConstructionSupersisor(CSL) P1*7 % �V 49 Ado" Licenx.Number Espuauon Oate N•yoe 11 L-=y Lw CSL Type Ixr helurl Address17 / T Description ` U Unresmcted u to 35.000 Cu. Ft. R Restricted let2 FamilyDwelling Sid r .,vfason Unl �J(�/ of 1.6* RC It Rooting Covering Telephone W S Residential Window and Siding SF Residential Solid Fuel Burnet Appliance Installation 0 Residential Demolition 5.2 Regis ed HoJ-ime Improvepteot Contractor(HIC) Z/ �7 HIC Company Name or'HI C rpstf(roant Name Registration Number Address AetL Expublion Due Signature I/Y Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2./ 2SC(6)) Workers Compensation Insurance afridavil must be completed and submitted with Ibis application. Failure to provide this andavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes.......... O No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN O R'S GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, cl- as Owner of the subject property hereby aulhorize to act on my behalf,in all matters relative to work authorized by this building permit application. Z- >6 Si atureofOwner Data SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 1, ��C'^ ,as Owner or uthorized A hereby declare that the sutemenu and i formation on the foregoing application are true and accurate, knowledge and behalf. 4 Prints /J e Signature of Owner or Autrionzed Agent Date (Signed under the pains and penalties of perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration program or guaranty fund under M.G.L. c. Ie2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110.RJ,respectively. 2. When substantial work is planned,provide the information below Total floors area(Sq. Fl.) (including garage, finished basemenuanics,decks or porch) Gross living area(Sq. Ft.) Habitable room count 'Number of firepixes Number of bedrooms Number of bathrooms Number of half.baths Type of heating system Number of decks porches npeof cooling syvtem Enclo.ed Open -� 'Tout Protect Square Footage' may he.uh.ntuted for 'Total Prolcct Cost" r CITY OF SALEM ? ,Joe, PUBLIC PROPRERTY �',,a►/ DEPARTMENT 1'.II:. MI h1 !'KN,'41 >I;II'n - I'C�.\il ll\L�,IN$1,"LET#S.\t l]I, IF I:978.74 '1995 •1'.\X:979-740-4X16 Construction Debris Disposal Affidavit (required liar all dcnolition mid 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 At is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: Iname fhauler) The debris will be disposed of in : ptarrle of TaclTnyT— ��,�,,, plddrnss"r facility/ signature tw permit applic nt date ..� CITY OF S.U.E.`I, NLkSSACHUSEM BL'ILDLNG DEnILTS11UNT /r 120 WASHINGTON STREET, Yo FLOOR a� TM (978) 745.9595 FAX(978) 740.984 KI%iD Rf FY DRISCOLL MAYOR 71-MM sST.PtERRs DIRECTOR Or Pl.BLIC PROPERTY/BCRDOM COMRSSIONiER Workers' Compensation Insurance AMdavit: guilders/Contractors/ElectrlcirnslPlumben Anolle2at In nrmatlo Lq / Plean Print Legibly Natnte(Bttsineu.Orgatetruionitdevtduaf): - 541 V Address: City/State/zip: Phone N: 7(-/ d''i P lCl o Ire yo as empteya►!Cheers the appropriate boa: Typo of project(required): I. 1 am a employer with L- e. 0 1 am a general contractor and I employees(full and/or pan-time).• have hired the st&corltraceors 6. ❑New construction 2.0 1 am a sole proprietor or partner. listed on the attached sheet : 7. 0 Remodeling ;hip and have no employees These sub-contnftoes have B. 0 Demolition working for rise in any capacity. works"'comp.inwmaca 9. building addition f I No workers'comp insurance S. 0 We are a corporaeee and id ruyuired.1 odicers have exercised their 10.0 Electrical repairs or additions 1.❑ I am a homeowner doing all work right of eaamprion par MOL 11.0 Plumbing repairs or additions myself.(N'o worker.'comp. C. 132,41(4L and we have no 12.0 Roof"pain insurance required.)I employees.(No worker' comp insurance required.) 13 D Other •Any appurant this tdtecka bat el matt 21r no tact the mime balow dhowity Their work se'wtttI tooloo PdK'y inasntarlata 'I hinimawtws who sokntii thk+aflldevk indicates they am doing all ask am that him wend♦Leteere"rawer ahmit a ttsw a111,Yvi1 irdityiea OWL :C.eatamte tMe ckaek this box cnW aeachee as atltati,ewl sheet eherity tea err M the wl�ssalmceofe and their waken'Cane•pdisy infamWon, l ear an emp/eyer that list nvidlwg worhat'eonspewaeden/ntenwn jor my treveyees, Qa/orritiformefim a she pNky ewdpl site Insurance Company Vame:_, +/ � Policy a tx Self-iris.Lie.M: Wf- Ce- (,0�i4l 7LYl Expiration Data:_.r lf/J d Job Sire Addkers:�/ f/f'�^'v'"' �r City/StatWZip: �R4 04 d/7)D %Crack a copy of the werhen'compsnsatbn poUcy deeentlea pap(showing the policy member and expiration date)6 Failure to secure coverage as required under Section 23A of NGL c. 132 can Ind to the imposition of criminal penalties ofa fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in rise form of*STOP WORK ORDER and a floe Of up to S250.00 a day against the violator. lie advi-Od that a dxrpy of this statement maybe rurwurded to the Oi7lce of Invc,ttgatiuns alike 1`31A for insurance coverage verification, l de hereby c•ertljy art r e p . u Rallies el per/ury that the injorneer/ow provided above is trot awd torreaa ' :" t ,✓ Phoned• L.p J fY O/Jiciel use atdy, no nor write its this area,to be ratwp/rlyd by Lily or tows of/&/at ._ i City or ruwn: YrrmitlLlecnu M i I,suinti Authurity(circle tine): 1. Ituard ui Iltallh 2. Ruilding Department I Caytrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6,Or her l_utetacl Person: _ ._ -_ Phonee• r i vk°+ rp.i .oz 'l:rl � 5 � lwl 141. YI' i'I u t V r ♦♦!! ir '"'f r {{�ri'Jet. �l`,r'1 'Vp1 ''xt ,' y$ ' 1 Ik .. ..._.. ....,...._ .. ._ .. .. _ .._..ter n... fn U W Z C a [�Q Q \� LL Z fl 1 �� Q o Z. > O LU o p w u. DATE: Citp Df a�afem' 1Eag5aLbU5ett- PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED p� Location of Building / 9 2LdZi / . Building Permit Application For: el '(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool Addition, Alteration, Repair/Replace, Foundation Only, Wrecking Other: /oT Mrv,ca, ywi1 0 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: Owners Name: 114rZa Contractor: Street City Street City c, State Phone ( ) Stat� Phone(ft) 70 Architect: City of Salem LicA/3 Street City State Lic# �HIP# State Phone ( ) Homeowners Exempt Form__yes no Structure: (please circle) Ingle Famil Multi Family# Other Estimated Cost of job$�2b' DOCJ. r l'r-V ( , Will building confirm to law? yes no V Asbestos?_yes /oo Description of work to be done: Drawings tSubmitted: __yes_� no Mail Permit to:,(----1b Signature of Application, IGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BEii`COMPLETED WITHIN SIX(6) MONTHS OF PERMIT ISSUED DATE Departm nntt use only: Permit#� `L Zoning Map/Lot Permit fee S►�\' V COMMENTS: (..ommonwea&L of i�a»acncc5eEEs �L.Jenarlman! 19,��,�r�a!_�«�aan<, n 600 VVaanin9lon Slreef James d.Camooed J,oslon. 11xMacnnae[G 021 It Commissioner Workers' Compensation insurance Affidavit I, I ef-2� IYt>.,w,ew.aaeet with a principal place of business ac. 1t7annowa.os � do hereby certify under the pains and penalties of perjury, that: I am an employer providing workers' compensation coverage for my employees working on this job. nsuranc Comp ray Policy Number () 1 am a sole proprietor and have no one working for me in any capacity. I am a sole proprietor, general contractor or homeowner (circle one) and have hired do contractors listed below who have the following workers' compensation policier. Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I understand that a coon of this statement win be forwaraea to the ORice of Inmucauons of the DIA for coverage venFieaoan and that ULWM m tang coverage as reduced under Section ZSA of MGL I52 an lead to me min wn of mmmn Den ltin consdttng of a One cif no go S I.So0.00 andfdr w yeas' cooraomnent as wen n Cron oenames In me forte of a STOP WORK ORDER and a fine of S 100.00 a day agama me- Signed this 1,1) day of /f Licensee%Pe nictee Building Depa ment Licensing Board Selectmen Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 40S, 409. 37S (1lt U of FIlPI11, II��arhumtts rr. �ubiic �rnputg �=partmcnt 'Juilhing 1tpartmtnt (encbvdrrn Srrrn 509-745=9595 frt. 3E0 DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 4a11S54, 1 acknowledge resulting fthatrom tas 8 .. condition of Building Permit 0 he construction activity governed 6y this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c III, S 150A. The debris will be disposed of at: location of faci iity Date Signature or Permit Applicant Fully complete the following information: (Please print clearly) fit s,v i Name of Permic Applicant T � 1DIVEVbCo Inlc Firm Name, if any 1/l bsr�a?�I� S� S,���m {'✓!/� of 970 Address. City 6 State The above statute requires that debris from the demol:tion.. renovation, rehab or ,other alteration of building or structure be disposed of in a properly licensed solid waste disposal facility as defined by. MGL cIII,' S150A and that building permits or license's are to indicate the location of the facility at 4PINSIAUKIM LtE 4M APPH0vjW aY Re MiPW9 PRW TD A PEBW fl<EM GRANTkD CITY OF SALEM � wam bar" n. a "o ram" r, t aaaeao. of �.CM�Iprlo Glrllol4 Yak�No ULM," IZ �ti as�iti� Y ill toowd In BINLDMKi PERMMT APPLICATION PM Pannt;to: 00b whW*wr apply) OUarSwft Carrww DUK &W, Pool. M&N E PE,L OUr UMLY A CMPUff&Y TO AVOID DELAYS N PROCUWn TO THE INSPECTOR OF MALDING&The WdW$OW '• hanby appNm for a PWMk to bWd acmditto to fdowft Owws No" Arohb t'a Name Address A Phone Madani= Nam. Ad*M A Pham IS-d d tl 0Y/) mly e,rs v "m M ft pu0oaa it haldrip91Z- wr.wof tar�gt s ar a V .to how ear W~ w•�q oodoaa b Irw9 aa..�en 920F ftd=d _ ?y -w Car umm# taw.uoaa. 7 S 7 6 NNW 3WdA n of Appli t eIONEo 1NrDEII 10 PW4ALTY' OP PfdfAIIIRY oEfl<cnPnoN OF WOW TO sE DONE MAIL PERMIT TO: IJJ �is rr{�j SF3t MKO O UOi33dSNl NOLLV= �1,44{sAy/ -Jad tL2�57 t1l Va au.j a LVA NMYor klv cyVN so aR !I q,�mmd 'k�s4i Jo oopesR wp IFWW io tesodnp M a !1-Jt#a."MP Pug W IS' *Wx J41, m9m; R 4F I'PR Ps + "s sr PnodrlP sq ampw jo sow[mq Jo w.mu e ww *M"Olu tiopgow sT mv mm pql ulpibu slnsn s sue, ter.�x�ta tlmv�a�•�x Q (Amrvlmmw •VAS ,� P WOOM �n Q I d1Aadls ssA�'I WlljMsWKAqpm"n6AWqj mill s�4lfa l�')I dl�dod s oIp t�W sq RP Rs� s!W J9 t+s�� d1!wRe sops►paoo s�sy AuPlsw,�s}qq R'--A R��QsHls �tt�•w� I YEti b►s 7DP[1s�ooppw�d sW 4ur soa�p�000�� JIAVm 3Y=ua io wsoma wDAV" 7Q 'iOMO§n Y A"VSS ssssv►c au> NVA osc •arcs ssss-s►c wsf -ul ou w va�s�rs imowu OYL 'assnas maim sm at I lasNtwgOALYs+OYd Dnorw wALxsn"*vssvW •wswS 90 ALI* AWanmem of inauwrrat eecraenrs O,PCe ofInvesdefidons 9 600 Waskinaton Shteet Boston.MA 02111 wtvwatausewrila Workers'Compensation Insurance AfMavit: BaNdaWontractor8/Electrkkuw'Plumbers ADDHcant Information fleas Priat LAmftW Name %� v ) ^°� Address• CitYAMw7* 0//�G Phone 0:_ Par ? � o Are y n employe?Cheek the appropriate tarot Type otprolect(npWern: 1.[�J t am a avlo ar with 4. 0 I am a Smear oonaaclor and I employees Ohs and/or part-dow}e have hired to � ❑New conrpoctioan 2.0 I am a sole"V icow of partner- NOW on the attached shear t 7. 0 Remodeling ship and bm no employed These sob oontracsors hsw 8. ❑ DCMHdm waling t v me i,any capacity. vultmo Comp.ioa inn y ❑ Bdft addido, [No wmkem'Comp.macrons 3. �] We are a cwporadoa add its os have exeseised their 10.0 Ehutrieal repairs or addi� 3.0 I bouteowne i Sica doing all work Halo ofcorf on per MGL 11.0 Vangwgnpm or additiow myscK[No wakes'comp, a 132,11(41 and we have no 12.0/Roof repairs ittsaanoe regaiiad) empkryas.[No workers' 13.0 Othta Comp.maaance nquuved.) •AnyappliaeatGwdwIabaneftwwdwsnoatossetkubelowAmbgG*rotas'w"@" =politykhm" o . Homeowwn rho mhmk Ns ofdav@ isdicdn @my as does an wok cad aba bum Collie ooaftedon=M1 aabmk a am d6hvk ioteat%x melt tCaooaetam 90 fbed No bane mat dacbed a da0aw Awt ouorus td wM ofdto mAlvaaatan and dAk woekes•amµ pommy Wormwioa ran a•fatplfyp tbdr(fO/OY g MOr�Qa'efapsaaarlpa btfMraaef fM asptfyefa Bftow 6 dw0 ft and job JffiM h on e*& InsuranccCompanyNarm: Policy N or SeV-ins Lit N / Expiration Date: /L f0 Iob Site Address: l9 ! , o`✓O S� ( y/Sy�: G� /�+s 7 Attach a copy of the workers'compessudes poiley declaration page(d wwleg the polky amber and e:piratlo date). Failure to acane coverage as regtmed unda Section 25A of MGL a 152 can Ind to the imposidon ofcrhr"penalties of a tine up to$1.500.00 and/or otrayear imprisonment,a,well as dvil penalties in the from ofa STOP WORK ORDER and a tine of up lo$250 00 a day against to violmr. Be advised that a Copy of this aatemeat may be tbrwarded to the Of&x Of Investigations of the DIA for insurance Coverage veri5estim I der Amyessl&am Am aleps6u mdpawMw ofpwjary Mar ahf IN&=faloa prvw&d abew b ow art earP � i Phone k ? r/ S-V' t i 30 �W art m6t Dr sod xw*in+lib wed,a.be eoaptd d y eig'or ap"*jL.,ed City or Town: Parmk/Lanse x /aalq Authority(tdrde ate): I.Board of Health L Building Department 3.CitYfrowe Clerk 4.Electrical Inapedor S.Plumbing Inspector G.Other Contact Ferso,: Phone 0: Massacbusem General Laws��152 tequva all e�bytaa p provide vm funder any�coonntract of bite, purruant to d1b statate, an ex~is defined as"•••�Y pWm in the service o of another C or VhA oral or writoea �� i �$�;corporation fir other legal eaiity+�9IIY rerun or more An enptoya is defined as"an ail+p ad to l� "a of.deceased e>nploYQ• tha d in a joint emaprow, of the faregoiag aaociatioa or oia legal amdY,empbYiag�lny0°a' � receiver of trW10e o bouu hsvio[tnt�d"dome aparomem sm who resides thae�or 1!e ooeupaet � Owner house of mother who crup"WNW a do mrinteaaoa,aonaane�err repair�in be as cMIOYW ' or oa the g umb arbw7dia[ Ibaeb ttiafi ofsncl eruPloymeat or MGL ebaptes I52,125C(6)sla�that"every atme or heal keasisg agna7 shag w�tlioM the foaaa baiWlaV b�eommoawealtb tar aa7► renewal of a or t?ana�to operate a budem Oat wN I the htaeraaee eorva�s ro9!i!m' SJammeant W has unt produced oeeeptable our m y of ile poll"mbar tioaany,MM chapm OX 125C(7)omm"Ncliba me awn into any contact tX t0 performance of public wort UMB acceptable evedano of compliance wift the iaatranoe of Chit chap pr chapter bavebeea esented to rho contracting=SOti�Y•• Se bones that apply b yew situation and,if pkafe fill out the wo m a'aompemstion affidavit completely,by checking g wi&their certi8caod )of neaswY,supply>Ob'Od a)mm�e(IJ addren(m)and phone01,p)with no emploYea other rhos the sumb spa, I,itutoed Liabft C=Vm compeon i(Lug or Limited on IDmrance. If an LLC or UY doer bave members or partners,we net Tamedto carry vvorttaa employat+a pow,y required Be adwed that tbit trw affidsvh may be aobmtl0ed to the DWs*tnomt of htdttttsvit Alas be acre to idiP am data the affidavit, Tha aflidsvit ahouhi be returned n town s applinsuranceication i the permit hoem law meif YOU �io�a of ludaftrial Aaideatt ShmW you bave say quefmaa regarding at the t m*a bane"�� Self imtued conrptrma fhoatd eater weir compensstiaapolim p.* call the])epa Hna self-inaartmo Hoene amdrer dO the Ctq or Tows Olficims rt the botoom n oomPleOe and printed legibly. The Deparaanthas provided a spsa ucast please be me that ac affidavit. boa to contact you teis+d00g�apes of the affidavit for You to ®out in the eve w�bi&vv�be used as a reference anmber. In addition,an app� pleats be sue tD fM in the paw Hcadm in any given year,need only submit one affidavit indicating cauTent that aunt submit multiple permivHceafe apes or policy in o oadoa(if oeeatary)and ander"Job Site Address"the applicant ShDaht ma my be to Me mwo"A copy efth affidavit that hat boa of&ialty ttIeVa or� A affidavit mt be filled out each applicant err proof thel a valid aifidsvit>s oz filer for&sue permw not related to any business of conmtaaisl vealme year.Whoa a boma owner q cithm is obtaining a Hoof.or pe�imit to�Pio*b affidavit (ie.a dog Seem a �p °t io bsm leaves etc.)said pricer is NOT required The office otImeatigado°a would to thank you in advance for your cooperation aid ahoteld you have eery 4ueftiona+ please do>ntbcdM to glue of s cal The Dcpu mcWs adNaf,tekpbone and flirt flu Commonwealth of Massachusetts DepNMCM of Intbtstlial Accidents Once of Invetttleadom 600 WasbM&tofi Street gomso MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 geyind 5-2" www.mass.Bov/dia CkE i N �.�