41 BEAVER STREET - BUILDING JACKET � l ��A���� S�
. o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT -
e3i 120 WASHINGTON STREET, 3RD FLOOR
'f a SALEM, MAO 1970
TEL. (978) 745-9595 EXT. 380
- FAX (978) 740-9846
STANLEY J. LISOVICZ, JR.
MAYOR
July 23, 2003
To Whom it May Concern I
I have been asked to determine the legal use of the property located at 126-128-130
Boston Street and 41 Beaver Street.
The property consists of 4 buildings on one lot.
The layout is as follows;
126 Boston St. - 1 unit
128 Boston St. —2 units
130 Boston St. - 4 units
41 Beaver St. — 2 units
Total - 9 units
The property is located in a B-2 zone. The property is a grandfathered non-conforming
use.
Sincerely,
t
Thomas St. Pierre
Zoning Enforcement Officer
BEAVER STREET
o, � ,�,7ir/ECc�,✓� ;
- - - AREA : 18, 816S.F. t
� � I
•
i
i
f3� s
:,4a
IIV
BOSTON STREET
:CI77*,V ;AJfA cl4,uf c,n x
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DANIEL G
►AIA
SIIRVE't
l:•'tU lt{ =�illPlll, c��c�557C11L25Pff5
�r F �Iauning marl JUN Z1 153 Pr4 '88
«�sa @nr f-�alrm (6rrrn FILE#
FORM A - DECISION CITY CLERK. !
Ms. Josephine Fusco
City Clerk
City Hall
Salem, MA 01970
Dear Ms. Fusco:
At a regularly scheduled meeting of tt:e Sala-. Planning Board held
on June 16, 1988 it was voted to endorse "Approval Under Sub-
division Control Law Not Reauired" on the following described plan:
1. Applicant:
Robert Gauthier
130 Boston Street
Salem, MA 01970
2. Location and Description -
41 Beaver Street, Rear of 128, 130 Boston Street.
Deed of property records in Essex South District Registry.
Sincerely,
Walter Power III
Chairman
WP/sm
BOARDOFASSESSORS
�I' X
93 WASHINGTON STREET, CITY HALL, SALEM, MASSACHUSETTS 01970 (617)745-9595 Ext.261
kI r
July 28, 1988
Mrs. Josephine R. Fusco
City Clerk
City of Salem
Salem, MA 01970
Dear Mrs. Fusco:
Please be advised that the two-family dwelling to be construc-
ted on the rear portions of Assessors' Parcels 16-0158 and
16-0159 (126-130 Boston Street) has been assigned the street
address of 41 Beaver Street.1
1
ru y yours,
J '
Peter M. Caron
Chief Assessor
PMC:mjg
cc: Postmaster Joseph J. Leccese
Chief Joseph F. Sullivan, Fire Department
Margaret R. Hagerty, Principal Clerk, Water Dept.
/William H. Munroe, Inspector of Buildings
Engineering Dept. , City of Salem
Mr. Robert Gauthier, 130 Boston St. , Salem
a
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALF:M
Massachusetts State Building Code, 780 CMR, 7i°edition
(� J RevisrdJurniary
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• 10011
One-or vo-Fumily Dwelling
is S tion For Official Use O
Building Permit Number: Date Ap 2 t t
Signature:
Building Commis inner/Inspectt of Buil in Date
SkCXIqK I: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(@)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuired 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �[]
�c r�rm n �mS 41 Pn oC S1/ � 42 /'nl
Runic(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building hill Owner-Occupied J111 I Repairs(s) 19 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofricial Use Only
Labor and Materials
1.Building S Q,0() 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
- ❑Total Project Cost (hem 6)< multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List: r
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 5 a,SU ❑paid in Full ❑Outstanding Balance Due:
G
SECTIONS: CONSTRUCTION SERVICES r
5.1 Licensed Construction Supervisor(CSL) gy61^
rl
DeA[1':s m—^•',:5 License Number Fspimti n—Da te
Name ot'CSI.• I lolder QJ.J3,
/,nR List csL qpe(see below)
Address ' T Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signatu M Masonry Only
28I-2L45 -33Qf) RC Residential Ito,oling Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 �tegbtered HoJna Improvemeut Contractor(HIC) GO
�3e( (kjyz�t �rnS'ttt�[">47
HIC Company Name or fll s'Rrgistrartt Name Registration Number
�� ,n e7 'P�A r•)t't o)W, O
Address
-iat- 90-37oo ExoimfigfrtDate
Sf f Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........e No...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize t to act on my behalf,in all matters
relative to work authorized by this boil t g permit application.
s a6Al
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
Q n /
I. 9
nt3 1 1✓At is . A 1 ,as Owner or Authorized Agent hereby declare
that the statements and informati on the foregoing application are true and accurate,to the best of my knowledge and
behalf. ir
Lail
mint Name v
Signature wnero orized Agent - Date
(Signed 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 gpf have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 1 I0.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Q
ND• City of Salem Ward
�I
APPLICATION
Fon
PERMIT TO BUILD ADDITION, MAK19 ALTERATIONS OR NEW CONSTRUCTIOP
IIUPORTANT•ApplkaW to COM1916 aflltsim in sections:414 lll, N,and LK.
L. -... AT¢OCAT1oW 4I A�� �-1•� � � - 7A11i6
' Locanoa OISIIOCi
Op BETWEEN
BUILDING KMMg"'EffD
_ . SUBONISON. LOT a ocx LOT'
.S
I. TYPE AND COST OF BUILDING-All applic`aie6 compiete Parts k-'D ,
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR-DEMOLRIOW USE MOST RECENT USE
`. 1 Q Nere audid" R
2 ❑ AddNrnrNreaidanaeewWfiumbrOr�� 12 a On.YnW.. ; ,8 a.MewneN,tarJMlprl.•
liouW*unda added,d am:a par0.,3) 19 Q`C?wuM~raig"A
13 Q Two armoe rmay,-fnaar/errrrEer
3 wQ,r/Allmeuan/Sae 2 abonl a u va m 13 1�r.
4 W RePar rePMcanwn 14 [3 TranWW h0W nn"br donWa y• 21 Q.F%* 9ue0e
s��❑llW ngiNmA9�ly mdanW an-r,i mh r � En ,nvA&Waupa .22Q SMMEe Wul.la wipmie
of unda n buddip n Parr a 13) ,S ❑ Oaraaa 23 Q lreolrl,eaenmrw
8 Q MPurtP,reboliorrl •. 24 Q OPb.Wac Orbleeeorral
Is.a Carron .. - 25 Q Pubeb umv
7 a Farb lic, ow, 17 ❑ OPrr-Spiro - 2e a seWaldrw,wrr.eoarr
i a.OWNERSNIP 27 ❑ Slams nrrrareYe
21110,Unkii,meta
� B�/J�{�! Pnvar u,tliui0ual m+Po�arPn..ilOnPraIl_ ,
�. L KNEOmPn:e[d/ 29 ❑ Ww-sps v
9 Q Pubic lFedral.Stale.or dol on"rarklnl _ .._. . .. .
C.COST - IOrrYanw- N wmftnto-Oeeorbrn dew Proodaw use of buidaga,e.g..two amceeaaq pan&
mwhm arm Murry hddmg in bPePeeL Olen awy erhoa.samduy WhOM caeeaa 5
1a cm a enao anxmr s Paraa�raettboL P.r'' g wow rr eeown«a rwwta�Aw buiti i +wrw
. • brat pea:a us a exar,g buNOYq a atrrgw sea <
TO he - -
l is WYawn mar' T
a gweyco_
. b.Paarrbeq
c llaarla.ar mrdMariq ��
a O9r.lal.alor au
11. TOTAL COST OF IMPROVEMENT .
IL SELECTEp CHARACTERISTICS OF BUILDING -For new buildings and addiVotM,complete Parts E L;den oMbn,
COMP11100 On Iv J 8 M,all WWII Skio to IV
E. PRN CWAL TYPE OF FRAME F. PRMKM%L TYPE OF HEATING FUEL O. TYPE OF SEWAOE DOPOSAL L TYPE OF MECNAMWAL
. 30 i] '6bmtY(sae Werirg) 35 [] Oaa 40 i] Prrbaeor PdnWe MMW - Wo ara beul•lralair .
32 13 Sbrebrbl argil 37 i] E ,- ,r 41 Q RAala laaPle rnk.a,4 , mµrldAbrra4T w
No
33 0.Rmoxam coals 3e ❑ Car NL TYPE OF WATER SUPPLY a 1334 Q OVw.Spml. 3013 0aar-sommo 42 ❑ PabgearpharaarprlY 46 46 13 y Yraraarrr
❑ YYa 47 13 No
43 13 Prbal; %,K aarrrM
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48 Num W SIONSS ..._._....._.._._....____._....._..___
49, TOM aauM lam a aoW area Has Approval from Historical Commission been received
,:noWs oaa.a m� for any structure over filly(50)years? Yes_ No_
50. Tam unu au as IL..—_--- _ ft Safe Number
IL NUMBER of OFF-STREET PARKING SPACES Pest Control:
51 Enclmaa...__. ._ ,,._`...
— HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. 0u10mn..._ - -- Yes No
_ L RESWE W 1AL @ULM 8 OMY ' • `yam' ` -
53.EfCWW Ebcir '
Full
_ DOCUMENTATION FOR THE ABOVE MUST BE
Sk Nu toffs ATTACHED
"tlaOd~, . • FWW BEFORE A PERMIT CAN BE ISSUED.
` IV. COMPLETE THE FOLLOWING:,//
Historic District? Yes_ No d,;_ (ff yes,pie enclose documentation from Hist.Con) .
Conservation Area? Yea_ NOX (ff Yes:please encase Order of Conditions)
Has Fire Prevention appi awed and stamped Plans or applications? Yes_ Nox-
Is Property boated in the S.RA district? Yes_ No2L
Comply with Zoning? YEEX No_ (If no,enclose Board of Appeal dew=)
Is btgrandfatliered? ,Yes. ' No— (if yes,submit documentadonllf no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yes_ No—
Is Architectural Access Board approval required? Yes_ NoX- (If yes,submit documentation)
Massachusetts State Contractor License# Salem License#
Home Improvement Contractor# HomeoMmers Exempt form(f applicable) Yes_` No
CONSTRUCTION_ Tq BE COMMENCED, T WIT, SIX,(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
ubmit
CONSTRUCTION IS TO E6MPLETEd i writing to the I BY: S 5- ' extortion necessary'please s.
n Inspector of Buildings. ,
V. IDENTIFICATION- To be completed by all•appOcants:
N" Maip aemaaa•Mmmr,mram.C*ma arra ZIP CON TaL Na
Q.y.« awl?) 3q PAL ve- LyAW NO Q4 01ft ALA
z e� 5'T, e 01?k
a c C `1k - 57r ue"cs MA o1q,E3
Mapea or -
I h posed Pak a auMoraed by the owner of record and that I have been authorized by the owner to make this appliption
I as hi t unto tzed anD we to to all acalcable laws of this iurisdietbn. -
Sig re of Address ApplipatiM daze
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Burg. FOR DEPARTMENT USE Oran'
Permit number
Use Grow
Budding
Permit issued 79- Fis Gra*V
Budding- L vs losgir9
Permit Fee $
ocMosrry tcae
Certificate of Occupancy $
Approved by.
Drain Tile
Plan Review Fee e
TTTLE
NOTES AND Data•lFor department use)
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN•For Applicant Use
i
ON
1
I
I
i
i
AswAaw ��
A�
JV-IP'
171d1BY 'wllr� it MNi. r
CIOfL'7
A
l2NG[MI '
r-r ,r-r•
41 BEAVER STREET
2ND &OOR
a.Er = 52s
l CERTIFY THAT IRIS PLAN SNOWS UNIT12 BEING CONVEYED AND 7H£
IMMEDIA TE ADJOINING UNI75 AND IHA T /T FULL Y AND ACCURA7EL Y
DEPICTS 7HE LAYOUT, LOCH LION, DIMENSIONS, APPROXIMA X AREA, MAIN
ENTRANCE AND THE IMMEDIATE COMMON AREA 70 WHICH /T HAS ACCESS
A T 41 BEAVER STREET, SALEM, MASSACHUSETTS, AS-BUIL T.
DA 7E PROFESSIONAL LAND SURVEYOR
UNIT *2 HANCOCK Bt
BOSTON STREET Survey Associates, Inc.
185 CENTRE STREET, DANVERS, MA. 01923 DATE
CONDOMINIUM VOICE (978) 777-3050, FAX (978) 7.74-7816 2/14105
41 BEAVER S7R££T SCALE, 1" _ B' JOB
SALEM, MA 0 4 e 1s NO.
City of Salem ward
9
I
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTIOP
IMPORTANT•App**W to complete all items in sections:4 14114 IV,and hC
AT ILOCATWiA ,
ZONM
LOCATION
DISTRICT
O OF, Ci BETVI�N 1N D�1- ET � AM l�'RD✓� ST•
BUILDING aee anwle Ooeoea5ila@n
LOT,-" " l�
" .. Sl18GIVLSION. _LOT-SL.00Ic SUE •S'
IL TYPE AND COST OF BUILDING.AN appUca-'Complete Pads A D
A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOLITION-USE MOST RECENT USE, .
1 0 Now build" RaaWanba _ laaewawdndw- -
.. 2 0 AdMM lit m8dWMA wWiIumawwl nw 12 0 One ft* _ 1s Q NnMORWIL Me�W
_. h uW*unna addft dint.nVWQ 13) - 19 0 Clnrh aaar MhWA
13 0 Twoamon hnugr-Enw nu~ "
3 [1 ARaraon(Sw 2 abaw) of W" f 20❑.Wdus palft9in0a.
W RaOai repVra�r�t 140 TMniWh*W nc�la ft iftY• 21 0 SnMoawam mOw9aaYa
_ S 0 Wmckwq in rna4laneYl wwmamw . . 6wmMaiwauMs - - .
.- 23 0 HaebibA Ymmmnr..
of iah n aakwq n Pwr a 13) 16 Gaspe 24 0 Olew,bar&pa.eouw
_ S 0 KWAV lrNomeonl - - 19.0 cwwn _ 25 0 Pubic uWy . .
7 0 FoumaanaaT _ 17 ❑..ONM saw* -- _ = 0 3d �
S.OWNER SNP
&vta t 0.UskL owv�e q n♦OhdoKefe.) 0Off. it
28
:.
i9 0 Public iFewwl.Sole.a eaal powmnra -- .•- - - _
C.COST ICnsit - Noeawa muso-Oewaibs n deeei adaeeeeo uw a bul0iga 04..twd aebbiaee I ohnL
IM 18 anon.pu!av addiw at Xoapaw,eWnweMy aunK soom y Whal asap
1a Cwe a Ynalwamwo _ 3 ..: PaerJal edictal Paaaq pwapa lar d"Nowm aeom ewaa d 0 but&'M& budding. a" alYa.V uea asaiewq buewq s bwq anw mama
To Oa 6100ad Md1 W aaatiied"
In ft am"cm
a EhcMM_
R PYarweg
c. rlaaoq.ai analfwlYq - -
6 Dew lehralor.semi - -
. .11. TOTAL COST OF RWROMMiff -
UL SELECTED CHARACTERISTICS OF BUILDING "For new buildings and additipns,"complete Parts E-L:demolition,
cOMPWO on1v Parts J&A all others skip to N
E. PRAYCQ'AL TYPE OF FRAME P. PRNCiAL TrPE OF HEA79eS FUEL G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECHAINCAL
.. 3o O:Miaenvha�- w 35 0 Go 40 0 P1Eleaorm"conlawer"`. Vim OWN becw"41 ,
0: deal 37 0 w. . - 41 0 Pdrah laealm hral aw candlYang9
❑ Eipo ilY 44 0 n 49 0 No
33 O 11wdw dmeedwe 3613 Cam H. TYPE OF WATER SUPPLY WEtlenabMaee4waaolr
34 0 Odw•SawM' 39 0 Oew.SWO 42 0 Pubic apbaleewnpwry
4e O YM 47 0 No
. 43 13 ftmo onA,ahhlyd
j-OWNSIONS M. DEMOLITION OF STRUCTURES:
ss. Toy sown fW at eon 11 s Has Approval from Historical Commission been received
a::aooee,Dam on a shor 9 Yee_ NO—
meeona for any structure over idly(50)Years
50. TOW two a Safe Number
IC NUMBER OF OFF3TREET FARROW SPACES Pod Control;
51 Erma°
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
5z oulmos..__ -- Yes No
L RESB]�BUILDINGS ONY --
53
FLA
SC
Sewer :. -
"" N in0sr of DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
oawOo~< wt*. BEFORE A PERMIT CAN BE ISSUED. .
IV. COMPLETE THEFOLLOWNG:
Historic District? Yes_ Noy (d year please enclose documentation from HISL Corn.) -
ConservationArea. Yes--., ? s . . ,._
fVo (ti yes;please encl)se,Order of Conditional
Has Fire Prevention approved and stamped Plans or applications? Yes_ No•- '
Is property located in the'S.RA district? Yes_ No2L`
Comply with Zoning? Y No_ (if no.enclose Board of Appeal decision) .
Is Id grandfatliered? Yea, No_ (If yes,submit documenfationfd no,submit Board of Appeal decision)
t i
If new oo_natruction,has the proper Routing Slip been enclosed? Yes_ No_
_ Is Architectural Access Board approval.required? Yea_ NoX— (If yes,submit dacumentafbn)
Massachusetts State Contractor License* Salem License I
Home Improvement Contractor# Homeowners Exempt form(d applicable) YES—` .No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(e)MONTHS OF ISSUANCE OF BUILDING PERMIT 'J
If an extension is necessary,Please submit
CONSTRUCTION IS TO BE COMPLETED BY: S 0 . in writing to the inspector of Bufl&gL
V. IDL7iRIFICAMON• To be completed by W1 apr66i ors
Wnr MMne ammo',M°Mer.L"A oor.aro ads ZIP Coat Tel No. :.
O. or - C e 3 ry. IL ve LXPP NO MOP olft 69-
2. e� ic C1 Aymg -5:T, e D19fy0
a Ce �lke 57 VACS rAA o19,;zAmrAW 3 97�
or B
(
I hereby Ceray the Pro work b auaar¢Bd by the owner of record and erat I have been auma¢ad by the owner to malts aria application
as his sum O nee to to all aooficade laws of this wrisdiction. 1a !
Signeare AddreBs NIP_ Vnk
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building- FOR DEPARTMENT USE ONLY
Permit number
Building
use crow
Permit issued 18— Fie Gradiq
Building_, lns L
Permit Fee $
aaftq
Certificate of Occupancy $ Omsww�Load
Approved by.
Drain Tile $ Ly
Phan Review Fee S /
TITLE
NOTES AND Data•(For department use)
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE -
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES a .
rt t
SITE OR PLOT PLAN•For Applicant Use
i
i
l�
O _ � N
i10W0=, secreteMAW&W
f!t!b:
mAILMY
QD _ U"Rm
f�L/AIV/
aaarr
r-r
L
aroev
i fNll/Y V a�Wws Mu i
_r• ter•
aotY
L s�n�eorw �/
�agar 'i
MwAmw
sm�aov
41 BEAVER STREET
1ST a 00R
EZ£K = 4J8
I CER77FY THAT THIS PLAN SHOWS UNIT p BEING CONVEYED AND THE
IMMEDIATE ADJOINING UNITS AND THAT IT FULLY AND ACCURATELY
DEPICTS THE LAYOUT, LOCATION, DIMENSIONS, APPROXIMATE AREA, MAIN
ENTRANCE AND THE IMMEDIATE' COMMON AREA TO WHICH IT HAS ACCESS
AT 41 BEAVER STREET, SALEM, MASSACHUSETTS, AS-BOILL
DATE' PROFESSIONAL LAND SURWYOR
UNIT #1 HANCOCK cHK By
BOSTON STREET Survey Associates, Inc.
185 CENTRE STREET, DANVERS, MA. 01923 DATE.'
CONDOMINUM VOICE (978) 777-3050, FAX (978) 774-7816 2/14/05
41 SEA V£R S7R£ET SCALE 10 = 8' JOB
SALEM, MA► 0 4 8 /B NO.
a /Io ns n a K 1tYs- raer w f17
The Commonwealth of Massachusetts
Department of Industrial Accidents
600 Washington Street, rh Floor
Boston,Mass 02111
Workers'Com ensation Insurance Affidavit* Buildin lumbin lectrical Contractors
address:
city State•
LR' phone
w \41 `Ve t 2 IUt 9
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction emodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
__ _ - �1 am an employer prevtdmg-workers eomQettsauor,f°r!r' mPrsw s oe' ibh
tic
/ —
count Wrk
a i'H `.ek nG r?sr'g /Fq
em
"11, FAA Y S 1 }y
�ty� 1►� yin .k i �t � rf' ~., 44
iosuraua m r _
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
cim
=e? r t "� ijr •e.r
.r' + !'3
18a..tf ,r amq�,.Y_'< £ ✓lY Yro.L"4 x iM e
Failure to more coverage as required under Section SSA of MOL 133 ab lad to the Impmifbn of criminal
one yesrs'imprisonment as wen as civil penseeks of s One up to 51,500.00 and/or
penalda in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 oodentsud ibst o
copy of thh staument may rwa to the Oma of investigations of the DIA for coverage verifiatlou.
i do hereby certify der th an aid of pWjury that the information provided above is true and correct
Signature Date J�31D�
LC /gyp 'L Print name L® Phone M /7f7 7 o — QV q
Official use only do not write in this area to be completed by city or town official
city or town: permit/Bceme it
❑BulNiug Department
❑check irimmediste response is required ❑Liceosing Board
❑selettmeo's Ofiee
contact person: phone a; ❑Baith Department
iRr„w Seyr nxui ❑Other
FNIIecMI..- _ THIS CERTIFICATE IS ISSUED AS A MATTER OF LNFWIMATON
CASSDY ASSOCIATES NI'S AGCY ONLY AND CONFERS NO RIGHTS UPON TINS CERIIRCATL
Ta NIGH STREET ALTER
THIS OE TIFICATE DOER NOT AMEND, EIM0 OR
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 ExT. 380
FAX (978) 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 Perm>t-#---- - --- all debri&r-esulfing-from-the-construction-activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,S150A.
The debris will be disposed of at: tQ► c'11 Ve
Location of Facility
'7-lt3�05
lgnature of Permit cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
-La -O<'b e i A
Name of Permit Applicant
J�e-t►1t CV ue`nolJ
Firm Name,if any
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, S150A, and the building permits or licenses are to
indicate the location of the facility.