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IWAa y;+ f yy p ffi r U A p 18 BRIDGE STREET 877-13 ,cas#-- 31187— COMMONWEALTH OF MASSACHUSETTS ocPk: - CITY OF SALEM Lot: 0036 I !Category: REPAIRIREPLACE IPe�t# 877-13 - -jj BUILDING PERMIT Project# JS-2013-002720 Est. Cost: $12,000.00 Fee Charged: $13200 Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO: Const.Class. Contractor: License: Expires: Use Group: Anthony Bellante General Contractor-62201 Lot Srze(sq. rt.): 4350.0204 -- Owner: MARIGOT BAY REAL I Y,LLC,JAGOL'JA RICHARD W IZoning: R2 Units Gained: I Applicant: Anthony Bellante ;Units Lost: AT: 18 BRIDGE STREET jpig Safe#: ISSUED ON: 21-May-2013 AMENDED ON: EXPIRES ON: 21-Oct-2013 TO PERFORM THE FOLLOWING WORK: FRAME INTERIOR,NON BARING WALLS AND OTHER REPAIRS AS NOTED ON THE PERMIT APPLICATION jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: u"i Footings: Rough:/.;"i:L. I+ J- - h: Rough:�/� t Foundation:, - Final: inal: Final: Rough Frame: .41Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: - Oil: 1 1-1 Final: ' N Y "' House# Smoke:191 1 14111 Treasury: Water: Alarm: Assessor Sewer: Sprinklers: Final THIS PERMI,T MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION O OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2013-002947 21-May-13 1455 $137.00 - IMPORTANT:nklVKIEP OR CONTRACTOR MUST ARRANGE INSPECTIONS DURING CONSTRUCTION.SEE CURRENT BUILDING CODE CHAPTEF I FCR LIS-OF RFOUIP.FD INSPECTIONS. " CALL 976-619'-ti41 TO SC"-"I It F A&'ItJCPFC`Tlnn �GeoTMS®2013 Des Lauriers Municipal Solutions,Inc. CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,3' FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER June 23,2014 Marigot Bay Realty Trust Richard Jagolta-Trustee 41 Chestnut Street Salem Ma.01970 Re:18 Bridge Street Dear Mr. Jagolta, This letter is in regards to the parking space adjacent to the side street at 18 Bridge Street. Due to abutters complaints ,last winter, I attended a meeting at the property with Sgt. King and discussed the legality of this space. Subsequent to this meeting, I was able to make a determination that the parking space was either in the Public way or so close as to violate zoning . After checking with City Engineer, David Knowlton, we determined that the space actually encroaches on the Public way. I am aware that recently you approached the City Solicitor complaining about this determination. I took the time to review the Board of Appeals paperwork as well as listened to the tapes. There was virtually no mention of this space other than a quick reference by you. You did not ask for relief from setbacks for this space either. Additionally, only a sketch of the parking space was submitted not even showing the property lines. Regardless, the Zoning Board of Appeals has no jurisdiction over land that belongs to the Public Right of Way. To be clear, it is my opinion that this space is not legal and you are directed to stop using it immediately. If you feel you are aggrieved by this order,your appeal is to the Zoning Board of Appeals . Sincerely, ThoC-4astrw as Building Commissioner/Zoning Officer ���WTq4� CITY OF SALEM !\/ ASSACHUSETTS BOARD OF APPEAL a� j. 'r �'�� �� 12nAC_�>iu�cill�Siia:r:r � ��i i,�i,.AI ass v:u C�t:rrc 019'0 'II.ir:1)74'"1;-939 IC-\s:97s--?W-9$46 I�I:,ntratl.liY t�R151!it A. � o .AI APUIt W C'] fel � May 1, 2013 = t I .. -- D Decision rn _ Q City of Salem Zoning Board of Appeals N Petition of RICHARD JAGOLTA, requesting it modification of a special permit per Sec. 3.3.2 of the Salem "Zoning Ordinance, in order to allow the first floor unit of a two-family building to be split into a residential and commercial unit at the property located at 8 BRIDGE ST (112 Zoning District). rA public hearing on the above Petition was opened on February 20, 2013 pursuant to Mass General Law Ch. 40A, § 11. The hearing was continued on continued on February 20, 2013 and March 20, 2013, and was closed on April 17, 2013 with the following Zoning Board of .Appeals members present: Annie Harris (Vice Chair), Richard Dionne, N'like Duffv, Tom Watkins and Jimmy Tsitsinos (,-Alternate). The Board of Appeals numbers absent from the hearing included Rebecca Curran (Chair) and David Eppley (Alternate). Petitioner seeks it Special Permit pursuant to Section 3.3.2 Nonolulb nruno Ure.r of the City of Salem Zoning Ordinances. Statements of fact: l_ Richard)agolta presented the petition for the property at 18 Bridge Street (R2 Zoning District. 2. [n the petition,January 29, 2013, the petitioner requested the mortification ofit Special Pernut per Sec. 3.3.2. of the Salem Zoning Ordinance in order to allow the first floor unit of a two-familv building to be split into it residential and commercial unit at the property located at 18 Bridge Street. At the April 17, 2013 regular meeting, the petitioner provided supplementart plans and doCUntenMtion for consideration. 3. The petitioner is requesting the modification of the Special permit so the property may contain two residential rental units and one commercial rental unit. 4. .At the first hearing for this petition one member of the public was in attendance and spokee in opposition to the petition. Written comments submitted by Mr. Kelh' (18 Bridge Street, Salem) and Mr. Wyman ('14 l3ridge Street, Salem) supporting the petition were presented at the public hearing. \[s. Flarris read comments of:AIr. Kathand \'vman into the record. 1lie Board of Appeal, after careful consideration of the eNidence presented at the public hearing, and after thorough review of the plans and.petition submitted, makes the following findings:__ 1. "Che desired Special permit modification may be granted without detriment to the public good and safety and without nullitring or substtntialk derogating from the intent or purpose of the Circ of Salem Zoning Ordinance. 2. The proposed use would not be nulre denimenrd to the neighborhood than the currenr uac configurarion. 3. In permitting such cllangC, the 13o:ud :Appeals requires cataiu appropriate conditions and safcgv:uds as nntcd bclo\c. Salem Board of Appeals May 1. 2013 Project: 13 Bridge Street Page 2 o1`2 On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to, the plans, documents and testimony, the Zoning Board of Appeals concludes: 1. The petitioner's Special Permit modification request to allow the first floor unit of a two-family building to be split into a residential and commercial unit is granted as conditioned. In consideration of the above, the Salem Board of :Appeals voted to approve the Special Permit modification request. ,All the members voted in favor, with a 5-0 vote in favor (Ms. Harris (Vice Chair), Mr. Dionne, Mr. Watkins, Mr. Duffy and Mr. Tsitsinos (Alternate)).and none opposed. The Board of :Appeals voted to grant petitioner's request for a Special Permit subject to the following terms, conditions, and safeguards: 1. Structure is limited to nvo residential units and one commercial unit. 2. The use of the commercial unit shall be limited to Business or Professional Offices and/or Service. 1 The commercial unit shall not exceed 550 sq. ft. 4. The Mitioner shall comply with all city and state statutes, ordinances, codes and regulations. 5. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner. 6. '\It requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 7. petitioner shall obtain a building permit prior to beginning any construction. S. Exterior finishes of the new construction shall be in harmony with the existing structure. 9. A Certificate of Occupancy is to be obtained. 10. A Certificate of Inspection is to be obtained. It. Petitioner is to obtain approval from any Citv Board or Commission having jurisdiction including, but not limited to, the planning Board. 12. Unless this Decision expressly provides otherwise, any zoning relief granted does not empower or authorize the petitioner to demolish or reconstruct the strucnue(s) located on the subject property to an extent of more than fifty percent (50%) of its floor area or more than fifty percent (5W. )) of its replacement cost at the time of dcstnlcton. if the structure is demolished by any means to an extent of more than fifty percent (50°/x)) of its replacement cost or more than fifty percent (50",'0) of its floor area at the time of destruction, it shall not be reconstructed except in conformiry with the provisions of the Ordinance. Annie Harris, Vice Chair Board of Appeals.___ -ACOPY OFTIIISDO ISION11Vi HI{GN F11,H)Wrtl-I'I'M'.II ANNINGB0 ARD:AND'rl-Ih'.it l'F I:LF:RK . Ipp d/ionr Mis feauon, q any. .bed/be owde punu,wl to S eaiou / n%late:Ilrr. thus l General 1<nnr Ch epler-N):-I, aud h-dl be pled within _'O dap )/ filing ol, Ibis deasmn in rhe n(Jie n/ Me 0!) (.ler( P rr.rnanl h Ire .Id n,rrdvaell, (wend Lnvr O rpl r N. 1. .$e fte4. (A I aO 10eual Peoull granted buxor L ul nu! la. r"jel,vigil a✓r,0) 0/Me e%e/inn hearirg"be Me Ca) c lery b,1S Guru filedwill, .\bill/, %rgL», o Deed.. 1 hereby csrtify that 20 daps have expired from the date this lr strome -iii avas u w eived, and that NO APPEAL has buen tial in thMce. "e ) A True Copy AT"TESr C17 Ci_EAK, Salem; A1856. 1 u ar CITY OF SALEM, MASSACHUSETTS BOARD OF APPEAL ^ 120 WASHINGTON STREET, 3RD FLOOR Irl SALEM, MASSACHUSETTS 01970 -_ - TELEPHONE: 978-745-9595 0� FAX: 978-740-9846 ti J KIMBERLEY DRISCOLL , MAYOR W C3 November 30, 2009 D Decision c Cry of Salem Zoning Board of Appeals Petition of RICHARD JAGOLTA(MARIGOT BAY REALTY), seeking a Professional Office Special Permit to use the first floor unit of a 2-unit building as both a residence and a home-based computer repair business on the property located at 18 BRIDGE STREET, Salem,MA(Residential Two-Family Zoning District). Petitioner seeks a Special Permit pursuant to the Salem Zoning Ordinance, §3.3.2, Nonconforming Uses. Statements of fact: 1. The owner of the property,Richard Jagolta, represented himself at the hearing. 2. In a petition dated October 29, 2009,the applicant requested a Special Permit to use the first floor unit for a residential use with a home business. 3. A public hearing on the above mentioned Petition was opened on November 18, 2009, pursuant to Mass General Law Ch. 40A, % 11. The pubic hearing was closed on November 18, 2009, with the following Zoning Board of Appeals members present: Richard Dionne (chairing the meeting),Becky Curran, Annie Harris, Beth Debski, and Jimmy Tsitsinos (alternate). 4. There was no public opposition at the meeting. 5. At its meeting on November 18, 2009, the Board of Appeals voted five (5) in favor and none (0) opposed to grant a Special Permit pursuant to §3.3.2, Nonconforming Uses. The Board of Appeal, after careful consideration of the evidence presented at the public hearing, and after thorough review of the plans and petition submitted, makes the following findings: I. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of' the zoning ordinance. r J � - 2. The proposed use would not be more detrimental to the neighborhoud than the current use. 3. In permitting such change, the Board of Appeals requires certain appropriate conditions and safeguards as noted below. On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to, the Plans, Documents and testimony, the Zoning Board of Appeals concludes: L A Special Permit is granted to allow the change from a nonconforming use (commercial) to a residence with a home-based business. In consideration of the above,the Salem Board of Appeals voted, five (5) in favor (Hams, Curran, Debski, Tsitsinos and Dionne) and none (0) opposed, to grant petitioner's requests for a Special Permit subject to the following terms, conditions, and safeguards: 1. Petitioner shall comply with all city and state statutes,ordinances, codes and regulations. 2. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 3. Petitioner shall obtain a building permit prior to beginning any construction. 4. A Certificate of Occupancy is to be obtained. Richard Dionne Salem Zoning Board of Appeals A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any,shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the office of the City Clerk. Pursuant to the Massachusetts General Laws Chapter 40A, Section 11,the Variance or Special Permit granted herein shall not take effect until a copy of the decision bearing the certificate of the City Clerk has been filed with the Essex South Registry of Deeds. �. n �&L, .�o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 53 120 WASHINGTON STREET, 3RD FLOOR f aSALEM, MA O 1970 •�,QMI�Wr' TEL. (978) 745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. PETER STROUT, DIRECTOR OF PUBLIC PROPERTY MAYOR January 28, 2002 Paula Rocca 18 Bridge Street Salem, Ma. 01970 RE: 18 Bridge Street R2 Zoning District Dear Mrs. Rocca: According to the City of Salem Zoning Ordinance Section 8-4, paragraph 2 states that should such structure be destroyed by any means to an extent of more than 50% of its replacement cost or more than 50% of its floor area at the time of destruction it shall not be reconstructed except in conformity with the provisions of this ordinance. ;Sincerely eter Strout Zoning Enforcement Officer Business Certificate Citp of 6aiem, Aassarbugettg a3 '3�ltt MII sa,� • r ou fr �, DATE FILED lqqy Type: New Expiration Date C D C ❑ Renewal, no change Number ❑ Renewal with chance In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of: 1. M SurLF 9YOcoLT 14oV type of business F7I S L \Iy 4 C K-1 fE— t e e b C by the following named person(s): (Include corporate name and title if corporate officer) Full Name Residence _YVIIcI� � cC-C- f9 Simon s � - - f---�- ---- ----------------------------------------------------- -------- --- -------------------------------------- ----------------------------------------------------- on 19A�Fihe above named person(s) personally appeared before me and made an oath that the foregoing statement is tete. ----------------------------------------------------- ----------------------------------------------------- CITY CLERK Notary Public (seal) Date Commission Expires identification Presented // p q State Tax I.D. # S.S.# 3 Z—Ll —D (if available) In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass. General Laws, business certificates shall be in effect for four(4) years from the date of issue and shall be renewed each four vears thereafter. A statement under oath must be filed with the town clerk upon discontinuing, retiring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation continues. Business Certificate v6��o o �itp of feaiem, faggacbUgettg �hlNg W DATE FILED ,Vr�� d4 zf1f Type: Q-'New Expiration Date ❑ Renewal, no change Number— -��9 ❑ Renewal with change In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of: f-fCtncts Tn ani �N°�N) at. (S Far,dno Sfyeef SalCrn MA 01970 type of business PQ/a✓i 4 The✓c( ou by the following named person(s): (Include corporate name and title if corporate officer) Full Name Residence 7)0tUis 7^ ncc0. 16 8kida s4?—eeF Cctfem, MA 019/0 Si natures ._._._._._._._._._._._._._._._._._._._._._•_=_•_•_•_�_•_•_•_•_•_•_•_�_•_ -PQJJ9L -- r_arc-------------------------- --------------------------------------------------------- ----------------------------------------------------- on— C"' a� 19-&the above named person(s) personally appeared before me and made an oath that the foregoing statement is true. CIT Y CLERK - ----------------------------------------------------- Notary Public (seal) Date Commission Expires identification Presented State Tax I.D. # S.S. (if available) In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass. General. Laws, business certificates shall be in effect for four(4) years from tete date of issue and shall be renewed each four vears thereafter. A statement under oath must be filed with the town clerk upon discontinuing, retiring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation connnues. Ctg of �ttlem, �� ssttrl Ats3P '09 �s PnttrD of peal F c^ DECISION ON THE PETITION_OP_NEIL &-GLADYS MCMULLEN FOR A SPECIAL PERMIT AT 1,8 BRIDGE ST.t(R=2) A hearing on this petition was held July 5, 1989 with the following Board Members present: James Fleming, Chairman; Richard A. Bencal, Vice Chairman; John Nutting, Secretary; Edward Luzinski and Richard Febonio. Notice of the hearing was sent to abutters and others and notices of the hearing were properly published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. The petitioners, owners of the property, are seeking a special permit to extend a nonconforming structure and use to allow construction of an addition in this R-2 Zone. The provision of the Salem Zoning Ordinance which is applicable to this request for a Special PErmit is Section V B 10, which provides as follows: Notwithstanding anything to the contrary appearing in this Ordinance, the Board of Appeal may, in accordance with the procedure and conditions set forth in Section VIII F and IX D, grant Special Permits for alterations and reconstruction of non- conforming structures, and for changes, enlargement, extension or expansion of nonconforming lots, land, structures, and uses, provided, however, that such change, extension, enlargement or expansion shall not be substantially more detrimental than the existing nonconforming use to the neighborhood. In more general terms, this Board is, when reviewing Special Permit requests, guided by the rule that a Special Permit request may be granted upon a finding by the Board that the grant of the Special Permit will promote the public health, safety, convenience and welfare of the City's inhabitants. The Board of Appeal, after careful consideration of the evidence presented at the hearing, and after viewing the plans, makes the following findings of fact: 1 . There was no opposition. 2. The building has been used as both residential and business since 1969. 3. There are many other businesses in the area. On the basis of the above findings of fact, and on the evidence presented, the Board of Appeal concludes as follows: 1 . The grant of the Special Permit will promote the safety, convenience and welfare of the city's inhabitants. 2. The relief requested can be granted be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district or the purpose of the ordinance. DECISION ON THE PETITION OF NEIL & GLADYS MCMULLEN FOR A SPECIAL PERMIT AT 18 BRIDGE ST, SALEM page two Therefore, the Zoning Board of Appeal voted unanimously, 5-0, to grant the Special Permit requested, subject to the following conditions: 1 . All construction be done as per existing City and State Buildings Codes and with a legal building permit. 2. All dimensions be as per the plans submitted. 3. Petitioner meet all requirements of the Salem Fire Department. 4. Exterior finishes and windows be in harmony with the existing structure. 7. No windows or doors on the new addition be placed on the side facing 20 Bridge Street. GRANTED Achard A. Bencal, Vice Chairman COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK frcm ' — L,:cJsloh, If any, shall be made pj:i-giant to Section 17 of .:las l.ar,eral La•,vc, Chapter .,^;C3, aad shall be filed vdthin 20 days rar tr.o date of f,Iin rf ;his dedscr. ir, the office of the City Clerk. So--:•on 11, the variance ;,.i ,=ke effect until a copthe efn:sbn. ne no -r :i,e City Clerk that 20 dayshavea'sed and no ePpea ha been Fled, or that, if such appeal has been filed, :hat it has teen dismissed o: den-ed is recorded ii the South Essex Registry of Deeds and indexed under the name or the owner of record or Is recorded and noted on the owner's Certificate of Title. BOARD OF APPEAL k, �h The Commonwealth of Massachusetts c Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One or Two-Family Dwelling his'SectionFor;OfficialUse:Onl Building Permit Number: `-'' °' rDateApplied ""'" 'Bu' Of c SECTION 1:LOCATION(Please.indicate Block,#;and Lot"#for locat'. ds for- - ' '- riot available - _: I R Ra�c a C o ) 97 No.and Street City/Town - Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK dP' Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No V Is an Independent Structural Engineering Peer Review'required? Yes ❑ No Brief Description of Proposed Work: - al rc"cy, A tw- &Ea.rC,�i,i G- tjA ((� 4!j Gear ' f 7 I7 a ft S��Q'(671_r dx�n.2 L{4 010 icc cc.i t r CM L Y2 ;ate, SECTION 3:COMPLETE.THIS SECTION,IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION;OR'. . . u., CHANGE IN USE OROCCUPANCY K :_.. - - Check here if an Existing Building Investigation and Evaluation is enclosed(See"780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION:4:BUILDING:HEIGHT AND;AREA' Existing " Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) a(Z Total Area(sq.ft.)and Total Height(ft.) ':SECTION SS USE GROUP(Check as'applicable). •_ - r'. ' A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑. M. Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: ,. SECTION 6i CONSTRUCTION TYPE.(Check a's,applicable) ;� IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB IY SECTION 7;SITE INFORMATION'(refer to 780CMR`111.0 foi details on each item)• Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Trench PermLicensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review PnKess: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ -.SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY - - Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: •:' ,,,r ;,.."`, ... -�.:,. °„`.SECTION;9:�PROPER'IXOWNER`AUTHORIZATION , h?"**'E, r,t. NqneandAcldre of Prop ty Ow er Name(Print) o.and Street City/Town Zip P er caner Contact Information: �2 J4 8-'`1C7 S88z7 �t/� �4 0 14 'v\c. yg,f Title Telephone No. (business) Telephone No. (cell) fie- a`t�il address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. - `s2 SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2) `IE build is less than 35,000 cu.ft of eneloseds ace and/or not under'Construcdon Control 0ieircheck here!O"and skr"Secuon 10.1 10:1 Re 'steted,Professional Res`onsible fox Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date '10.2 General Contractor)- ,- ` --+"+: r. " c, .k < • "'' i Company Name Plrua('Jy EeItArJc� CS 44-o Name of Person Responsible for Construction License No. and Type if Applicable JS (9RX-t.-r-\- AVC 6ksl— &Si o 4 0d1d Street Address City/Town State Zip -SGr IH� 61 1_-(0(0 0%6 4&4�o lol & 4-di, cym Telephone No. business Telephone No. cell e-mail address SECTION,11:4VURKLRSLCOMPENSATION.INSURANCE-AFFIDAVIT M:G.L.c.152:: -25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ 'SECTION 12:CONSTRUCTION COSTSANDTERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1 aJ 1. Building $ r7oov-Ua Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 7,T(J. VV appropriate municipal factor)_$ 3.Plumbing $ AVM- wo 4. Mechanical (HVAC) $ - Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ ( Vvy,°d (contact municipality)and write check number here ';'•', SECTION 13:-SIGNATURE OF BUILDING PERMIT APPLICANT, ,. By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is and accurate Ito the best of my knowledge and understanding. P ease print anjgn na e 00 Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector,to fill out this,section apon'application_approval .. . . .. Date Nartte,^ ` K:WS*"T-9EfRIE94AD APPROVED BY T44E J MPJECM PRIOR TDA.PERWT 9EING GRANTED CITY OF_SALEM No. \ Dot �� r� is Ply tae.aa to Location of I ar Nlatode oiddw YM No DoiMiaaS— w Pmpsey LWOW ti ft CwtawwWon Am? Yss No . BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof;Install) Construct Deck, Mwd, Pool, RepaidReplace. Other: PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The wr wagned hereby applies for a perma to build according to the following sp@WkaOons: pp Owner's Name C- �J.R�r01-W1 Address & Phone C#, f r No r S-r ( w) !�-V-sue Architect's Name Address & Phone ( ) Mechanics Name ?,yc11vt- I' �.✓ Address& Phone M ?a4s,"-v-r What Is to FXPaa of twYdnp9 r?,,j -�Le WwW a bAdltg? v 11 a dwNW*,for how many to naw? vm t Awv=Vann to law? AID t' Ed wad amf4 m Ctty LIMM 1 aor Lproaswsat Lie. i /�lzF-f S' o t ER THE PENALTY OF PERJURY DESCRIPT10 OF WORK TO BE DONE MAIL PERMIT T0: No. l -D APPLICATION FOR PERVT TO LOC ATION PERMIT GRANTED ©�- 2.0 AP v�o U INSPEGTOA OF BUILDINGS a k Permit Number APPLICATION FOR PERMIT TO ERECT A SIGN PERMIT MUST BE OBTAINED BEFORE SIGN IS FABRICATED AND INSTALLED Location,Ownership and Detail Must be Correct,Complete,and Legible 1N3Wd0I3A30 AllNf1WW00 9 9NINNVId 30'1d30 LOOZ o v fl�� City of SALEK MASSACAi F TO THE BUILDING INSPECTOR V The undersigned he eb(y;applies for a permit to Erect_Alter Repair a sign on the following described buildings: Location and No.1 X 30 <SL n Zoning/District /f Name of Property Owner ne 4 c ,- ,rc . af- �cti. . � n Name of Sign Owner! if Q R A 11 � 0' �A 11 i P Address 2 2 (3A ACF)f W R d 0,q l dY8 sf If Owner is a corporate body,name of responsible officer J Name of Licensed Signn�Erector ion M Q l/��Jh ! ,�/L�fS�Salem License No. ` Address S L/" � /lO{G�'/ , CtJ 0l! �� Use of Building: 1a Floor / 3-d Floor 2"d Floor 4,h Floor Frontage: Building Iva linear ft Property 119 linear ft Type of Sign Proposed: ❑ Surface Right Angles to Building Free Standing Awning Other(specify) Proposed Sign Materials (-/ .�A - Proposed Sign Dimensions x L', Sign Area sq ft Existing Signs: Surface: Sign Area sq ft Right Angles: Sign Area sq ft Free Standing: Sign Area aq ft Other. Sign Area sq ft Signs to be Removed: Type - Sign Area sq ft Signature of Owner ?rD per ty C Signature of OwneP 2 u2�Cr Estimated Cost of Net Work � Address vN ait S 775� Telephone Signature of Property Owner SLt, OLWVC APPROVALS(Department Use Only): COMMUNITY DEYEI.OPMENT HISTORICAL COMMISSION BUILDING INSPECTOR rii `� ,d �aiD9/'Ii�L �` \^�\ _ .. . ... ,.b,_ .:I i I - PUBLIC PROPERTY DEPARTMENT KINMM w DRW:ULL MAYOR 121 W.SMNG"N'MEEr•war.%%AACHLShTIS 01970 TM-979-74S-959S*FAX 976-740.98" APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION, DEMOLITION OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING STRUCTURE OR BUILDING rSITERMATIONe: Building: (�ess: ocated Ina; Conservation Area YIN Ahp Historic Dlatrlot Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: Address: _S41" I-A Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN ulwaNe, BUILDINGS ONLY Addition Existing Renovation ✓l Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated �S' construction or renovation of existing building New Sri& Description of ProposedWork:/ / > ---- - ------.Mail Permit to: --- What is the current use of the Building? Material of Building? 41-)Cm cJ If dwelling, how many units? Will the Building Conform to Law? z f Asbestos? Architect's Name Address and Phone 1 Mechanic's Name -- - r kN✓�'L��" - Address and Phone Af Construction Supervisors License#f106,57CC HIC Registration# Estimated Cost pf Project$ c�'��� Permit Fee Calculation Permit Fee i / O- — Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to uild to the above stated specifications. Signed under penalty of perjuryK,15 �— ate �7 `vl 17, �N N y i w a N o ° ---- C1�. 10 — -- - T LAND i ,VEYS � 2005 J D E ON SITE 0 'RIFFIN, ARCHITECT PA'(fZ00 \ �� REET / 90 �, �AtZfzi✓LL . / 7 .� 2 k4Y8 8 S o� � ti 84 ° >2 I1 O 2 wl CV ke) ki 40' CO M M ;4j VI �rQ A3 , ,2 O A� \ Ut 28'-0" 5'4112" 7'4" 7r 10'-8" '-4'-101120 ro•..•r .e-0• .ro•..•.a• v v bl , i (p 4 ' $maKe ,- a a 7'-6" O N 213" T-3" a a s-0•x S6' , �I (1 21jI�'N 2, 1 2"' Y YE•A•Po S � N V.� f N � sn L/ CO a-0•.s•-e•vo El 0 . v, O a i a e ® o saas•-0ryso 7 " 9'-4 9/16" 11'-1 7116"� 28'- ' b 12 p f Deck Elevation 2' from ground Railing Height 36" 1 Fvd7'h% Farrell 1 Smith Avenue y ' -Ieel Salem, MA 01970 1st Floor Apartment 28'—O — 5'-4 1/2"— -6'-8" F— 11 _1" — —4'-10 1/2" { 4 O Den t 2 � 06 � A6.6'a.9d aiN'_I rI, I Back Hall N stairwa y Dlor smoke Detector Livingroom ® i Y ,4 KitchenLO rLM g J T--r 1/2"-2 5 1/25 2=6" —3'-8"--"-5'-1 1/2" --Y-10 -- -- ----- — 28'-0"--- Farrell 1 Smith Avenue Salem. MA 01970 2nd Floor Apartment za'-o" ; Ctsefi —A OocXn 97 15/1fi- - x-11 1116 oFf ice i Smoke q ,L, 9'-71&16" Detector o`.,' Bedroom ��1;- EITU 81 , N Bathroom i 3'-2 0 � . o rn n SA•xBd-SD •� Tj a 6-31/2= ;' 21'-81/2" I I � i Farrell 1 Smith Avenue Salem. MA 01970 3rd Floor T LAND EYS 2005 IV z n•9 kTED N SITE RIFFIN, ARCHITECT 'REET 70 8 8 S6 I, a k� 7 'R ��° Q � v•3 �� '•q y \M� ,'„� � � i •8 - ��. TEA 1 p FFFF 76,1 N r �9. to i Gq�� �° � I � • w CC)MM V) zs zq ° f n N . 40 z tt� .J y A 28'-0" 5'4 112" — T-1" 10'-8" 4'-10 112" O � b ® (V0 Srrv�CL, ., V 7'-6" o N o2'-3"�l 7'-3" x Y�•x 6'd' 2 /rr_/11r 1 x 2' Y6 xB'8•PO o ems- N G Y C � 2'E'x 6'A"Po 3r-3`7�--31 rr 0 ' r v, O r s ® o 3'�8"x,6'd jSD 7 " 9'-4 9116" 11'-1 7116" 28'- / / z� 12P� Deck Elevation 2'from ground Railing Height 36" 1 J X/D �/ - Farrell 1 Smith Avenue iy 44eelo Salem, MA 01970 1st Floor Apartment lzv :. 0; 1TIC TA „ R4`•.. o-ak S.' a bil... ea �j ii r• n f3k� �.. �... i vS i; •mod' �. � J Y„ l x4' '• -- .w...;5;. ram. ..a art .a`,&% 3' Y, 1 a 1 28'-01- 5'-41/2` 6'-8" }` 11'-1" _ 4'401/2'4" aa•raa• a'oXa a - 3.Ora•-a' `\' � Smoke o, I' CO Leh Detector IVW . r =6 1/2'�=5-� 1 Back Hall r Stairway ?_m,4 lip, T ..� Smoke Detector Livingroom .,,. I KitcYten r�_ o i ici T-11/2',2=51/2.r2=6' —3'-8"--� 5'4.1/2"--+--5'4 Farrell I Smith Avenue Salem. MA 01970 2nd Floor Apartment I I i ,an <yx N 11'-3" OFFF {{ Ce AQ - 1 "' Smoke — —9-7 15/16" Detector o'. gam-� C Bedroom w ���� 81/�y 3'-2^ Bathroom I 4 \ I - 6-3 1/2"— 21;-8 1/2^ i Farrell 1 Smith Avenue Salem. MA 01970 3rd Floor T LAND �\ �[ 2-rI SMu ,VEYS � 'j 2005 �7z � I�.q A ,RIF N SITE GRIFFIN, ARCHITECT PATF�.tGK T. _ //m � • C BEET )y� 90 2 8 . . � rill''/ 0ki 4 ,� 8a 9 � 001 aA ° \ etc N0 Comm V) kel t„ �, 7,n�CC �S.2S Vol 0 o Go Sit iy (J ,y., n Ql4 °� 3 2 4T 0 �L hbA 1� ,23 R �1 0 The Commonwealth of Massachuscus Town of 11 t� Board of Building Regulations and Standards �� Massachusetts State Building Code, 780 CNIR. T"edition Building Dept Building Permit Application To Construct. Repair. Renovate Or Demolish a One. or Ti.u-Fuirolr DiveUmg This Sectio Fo Official Use Only Building Perrot Num lJoate Applied: 2 Sid atuK: Burldi isCommissioner/ ti o ridings Date SECTION 1:SITE INFORMATION 1.1 Pro pes0y Address: � / _s—f IY�_— 1.2 Assessors Map Ai Parcel NumbersM Number Parcel Number I.la 1:this an aec tied street'!yes ✓ no W IJ Zoning Information: 1.4 Property Dimensions: Zoning Distinct Proposed Use Lot Area(sq R) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rem Yard Required Provided Required Provided Required Provided ' 1.6 Water Supply:(M.G.L c.a0,Isa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system O Public O Private O Cheek if will SECTION 2: PROPERTY OWNERSHIP' 2.1 Owl 'of Re o / \ Name( ) ` ( Address for Service: Si ure Telephone SECTION): DESCRIPTION OF PROPOSED WORK"(ebeck sB tbst apply) New Construction O Eaisting Building O Owner-Occupied O 1 Repain(s) O Alteration(s) Addition O Demolition O Accessory Bldg. O Number of Units_ Other O Specify: Brief Description of Proposed Work": SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S Lt.OV fs I. Building Permit Fee: S Indicate how fee is determined: O Standard City/Town Application Fee 2 Elecincal S O Total Project Cost'(Item 6)it multiplier a J Plumbing S 2. Other Fen: f i. Mechanical (HVAC) S List: J Mechanical (Fire $ Total All Fees: S Su re.mon Check No. _Check Amount: Cash Amount:_ A Total Project Cost f J�Ja','J 0 Paid In Full 13 Ouutanding Balance Due: r t SECTION 3: CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor ICSL) r, Lwcn.e.Number Espwuon Dale N.lras of CSL Ilplder Li.t CSL Type(wc below) a AWress R Description stncted u to)5,000 Cu. Ft. icted Id2 Famd Dwelhn Stit"lure Unl ential Raofin Coverm Telephone Resident-al W endow and Stdm rnm A banes Insullatton ntial Demolition 3.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Due Sijputurt Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 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 Af►idavit Attached? Yes.......... O No...........O SECTION 72:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. X Print Name Signature of Owner or Authorized Agent Due (started under the prime and penalties ofperjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an uJ2nd ontractor (not registered in the Home Improvement Contractor(HIC)Program),will SA have access ton program or guaranty fund under M.G.L. C. I42A. Other important information on the HIC Pr Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and tively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) lincluding garage. finished basement/attiorch) Gross living area(Sq. Ft.) Habitable room count .Number of fireplaces Number of bedrooms Number of bathrooms Number of halfbaths Type of hearing system Number of decks/porches Typeofcoolmgsyslem Enclo.ed Open 1 ' Tool Project Square Footage" may he.uhstituted for 'Total Project Cost- '!e CITY OF SALEM jpg PUBLIC PROPRERTY N / DEPARTMENT \I ,gat 120IXAM[IN( :ov5rnerT st. M.t+imIa .rn,�t'i' rl: 978-74i-1595 I:n s:978.740-9846 Construction Debris Disposal Affidavit (required lur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tt __ 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 transported by: "(naf hauler) The debris will be disposed of in (name o1 facility) (address of facility; c signs ore of Ixr W applicant date �I CITY OF SM EM PUBLIC PROPERTY DEPARTMENT u)usatar Dnw.vv.- Vwroe 130v.SuNCTOMSIMM 9 SMAKMwaA0WLSF no19:0 Tti1.9'.L71}9s"9 P.%x 978.7469" HOMEOWNER LICENSE EXE.MMON Plea" "I pw /I 0 Job Location /F — - O �7— Home Owner Addt'aa Homo Owner Telephone - Presaat Mailing Addreas The current exemption of"Homeownee"was extasded to include owner-occupied dwellings of two Units or less and to allow such homeownm to that the owner acts>r �ge an pn�.vidual for a license hire who.don not possess pr'o DEFII=ON OF HOMEOWNER Persons) who owns a pared of land on which he/she resides or intends to reside. on s which there is, or i intended to be; a one or two family dwelling, attached or detached and/or farm structures. A n who constructs more accessory to such use P� strtsetttra ry than one home in a two year period shall not be considered a homeowner. Such -homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and uirements and that he/she Will comply with said procedures and it ents. HOMEOWNERS SIGNATURE .APPROVAL OF BUILDNG INSPECTOR See other side for state code 30 Dow b P"WIV Looter to � Of.., rr Irlmft OUIMaIt YM�Ns b Pm*mlV LOOM M rt C FA MNO A Ml► OUNLU" PWMMT APPLICATION FOR: Permit UK ��, Pool. (Ckde MdrWhWW M*) Roof. Rmon buo Skft prpNrlpaplrQa. Other; PLMAUUM PILL OUR U ML.Y A CO MMU V TO AMOID DMLAVO w PROCMON, TO THE INSPECTOR OF BUNLDINOS: Tha wWWWgrod MMW qom for a pawA to buM s000rdMp m 00 t ftv*p gwoftatlmra: � � G Owmes Nsma Adds a Phona Zj l hu/ ' f7 �R/ern (27f A-�O ArdYl ods Nama Address it Phone Moo wdm Nana _ 1—llJJ Ad*M A Phom 3Z.�71/0 ✓ S ��y �' j�71� 7.2 war b rM prpM d ourarjV - QnAlfa Mood trmrgt Glad �7 r•&A*&br now WARY ba�rbrr 2 ° Ylal tw111�11r a011101111 b bw9 6r.iwa oor cw umn• N A stw uomm• am ...` XG a UNrnMR TUUM PMNALTY OFPMUM OMSCRIP.WN OF WOIK TO U DONE n " 5P CPnJ �°5ress r/oo/ 0711.� .. - r�� s��u�f APPLICATION FOR PIMA I TO LOCATION PERMIT GRANTED DISPECTOIR OF SLA LDINGS Inc a,dmmvIVWV ....j ..........._.__�� Deparnacnt ojjndusoW Accfdints p Offlee Of l adoes 6" Wasl Vott Stared Boston,MA 02111 trtvtrtaaoxsaot✓Ai Worker'Compenaattoa Insuraace A®davit: BW der:ICoutradorsMecMd=sMumbeas A111111091 Iaf Plea Ptiat Lett Name 11 Address: J �7d"�y p 7 A C Dhow ✓ DJ7, Are you an empWar?Cbeel<tkr appropriate ban: TM dproled(*ev&VO• a a with 4. 0 I am a gertgal Cow and I 6 New confuocoon 1. I am employ • have hued the sob-�tra� awkwen(tag and/or time} = 7. ❑ Remodelimt 2.0 1 m a solo proprietor or Partaec fitted on die attached sheet for me in any cap B. 0 Dc=Hd n s hip and have no employee Thesesn .actors bare worl®g capacity comp. 10�a°0a 9. BaiJdmg addition INo �.ronop uisartince We area conwadon add ils 10.0 Electrical np*s or addition oflk=have exereued then or addition3.0 II sa a bbomeownot doing all work right of exemption per MGL 110>'Tr repairs mYscE [No v�lti1i• eonW' c. 152,41(4N and we hxve no 12.p Roof repaua bommoe requkaad]+ empcp�imm[No WOdWW ro4nuod 1. 13.0 Omer cheeb box 20 wolkMd�hh•oull MUMOMmMW=bma,xwwam&V'tbicenesuch tIi•meowrwt• .�mitPob•Iadavi�htdidthts did doing tConuedoee dat eheekon box mot thebed o edditiooel sheet showmK err mtr ofths abmonodwt exd obit•attar'emy.Paley ett'on*tettes. Jim a a swplsyedYat 6pfo>rdlittT workers'cserpeassdsa iasurswejor my Mploysss delsw It**psBq xxdjo8 star befm=arba InstaanCCCampanyNama policy p or Seat ms.Lic.M Expiration Date: Job sift Adareaa /�Y, rY e S C 1sialdzip: 1 11IQir, 001970 Attack a COPY of the workera',eompaa don po ft dedaratlon page(d weeing the Polley number and eViration date). parhae to sw"covaaV as regal cd nader Section 25A of MGL c. 132 can lead a the imposition of criminal penalties of a fine up w f 1,500.00 XWOf one-year*rbOuux-t,as well al civt7 peaahia in the fora of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy of this swcmem may be Aw* Med to the Office of Investigation of the DIA tit WW=ce Coverage vcdficAdm I As hereby ceno radn din AndpsaaB6s sf psf/nq am A*fafirwatloa P>nvldrd abrw Is brsJasl arse es 972 JC3�—179 O&W rise ouUt a.nor terdar ua liter a ,%a br sowpfesr/br dip Na m OJW City or Towa: Perait eem e/ Issuing Authority(drde ose)t 1.Board of Heakh 2.BWWing Depart meat 3.Ckyft own Clerk 4.Electrical Inspector S.Plauli ft Iaspector 6.Other Coatad Person: Phone r: Massachusetts General Laws chapter 152 requires all employers to provide workers'oampensation for their employeesk Pursuant to this stamae, an aaplayee is defined as"...every person in the service of another under any contrail of him- capers or implied,oral or written.' An aw,pfiyas is defined as"as individual,parmaship,aaoeinioA corpmatioa ct other legal entity,at nay two or rams of the foregoing engaged in a joint mterprisg and including the legal represco aava of a deceased employer,or thin receiver air trmte, of as iadipi&A per*association or other legal comy,employing employees. However the owner of a dwelling boaae having not more than three apertinexas ad who raids thesem,or the oaapam of the dwelling bonne of mother who employs persos a do maieftme ,construction as repsi work as such dwelling{Louse or on the grounds or bhuldiog appurtmam tbaeto shall not becaome of such erspbymem be deemed to be as employer." MGL chapter 152,125C(6)also saes that"aesy Aria w local Seeming*Vm y mhall withhold the imtmamee or remewd of a Skeane or permit to operate a business w to canstract bafidingm in the eommoawedils for ash appBeaW who ka sat produ M m eeptable evidesee of eompliamee with the hunramoe coverage rcgdret" III' Additionally.M(g..,ghapue[Ise.¢23q(7):cites"Netter the commonwealth we any of its political subdiviaoas shall am into nay comma Ibr the peribumma ofpublic wosk until acceptable evidence of compliance with to ismainee requirements of dris`chapter bave been presented to the eontractmj sutority." ti please fill out the workers'compensation affidavit completely,by cbeekiog the bona that apply to yogi situation and,if necasay,supply subconstaciaQ name ft xUress(ce)and phone number(s)akmi with their catiffcata(s)of maursom Limited Lab Compasid(L Q or Limited Liability Partnerships(I.L.P)with no employee other than she members or pmrmerf,ate not rcquhvd to carry worker'convemadm immssoe. If an LLC or LLF does have employes,a policy is required Be advised*9 this affidavit may be submitted to the Department of Industrial Aocidena for confirmation of im a ranee eoveraga Also be sore to dp and date the affidavit. lbe affidavit should be returned to the city as Iowa that the application tar the permit or license is being mNerted ad the Department of h druuw Accidents.. Should you have my questions regadmg the taw or if you an required a obtain a workers' oompeawdon policy,plesse call the Departnhut at the number listed below. Self-assured eompames should eater dick seffitrsrxarux license sp�opridte line Qty or Tows OfIIelali Please be sure that to affidavit is complete and printed legibly. The Depo rtmem has.provided a span at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regadiog the applicant Please be we to M in the permWdceme numbs which will be used as a reference mrmber. In addition,an applicant that mast submit multiple permittlicenm applications as any gives year need only submit one affidavit indicating an. policy mfetmanon(if uccemary)ad under"Job site AddresC the applicant shoakt write"an bcatbm in (dW or town}"A copy of the affidavit do has been officially stamped or orked by the city or town may be provided to the applieant err proof that a valid affidavit is os.f o fix bmre pamib or liceam A new affidavit must be fined out each year.whem a home owner ar cirmea it obWft a name or permit not mhned b any bnsiaas or commercial venture (im a dog liasse or peimit b burn leaves etc.)said pawn it NOT requited so amplese this affidwk The Office of Imea6gatiom would Min to thank you in advance for your cooperation and should you have any quadons, piic do not hesitate p gIa=s cWL The Department's addrm telephone and fin namDer The Commonwealth of Massachusetts Department of hidttsh W Accident Omce of Inveldgadtms 600 Washington street Boston,MA 02111 TeL #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised s-2tS OS www.mm.gov/dia t CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASSHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: s (Location of Facility) n 4reA�pplicant Date