14 AMERICA WAY - BPA-07-389 FINISH LOFT FOR BEDROOM EI`f�`QF"�r1L �-
�� � • PUBLIC PROPERTY �
," '�'"`'"� ������ DEPART'VIENT y,'
�/���,�-_ 97 i
I�I�MEIl1.EY DRISCOLL 7
MAYOR 1�WASHINGCfRI$'TREEL�tiAl l:�,�{,�itn(}{�Sh11S0197O �
'I'Fi 9'8-745-9595� Fnx:97&7a0-9&16 . "�
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEviOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: /�! �71f�v�� Lv� Buiiding:
Properry Address:
/y' /ja�����
PropeAy is located in a; Conservation Area Y/N Historic DfsVid Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: — _�_
Address:
/y s97'��c� �
Teiephone: Q7 7 �{� 6�/lZ
3.0 COMPLETE THIS SECTION FOR WORK IN FY�aT�N�= gUILDINGS ONLY
Addition Existing 3
Renovation Number of Stories Renovated �
Change in Use naw
^�T.�IiiiQ.^.
— � =xi3:lf:5
Approximate year of � Area per floor (s� Renovated
construction or renovation
of ezisting building New
8rief Description of Proposed Work:
���S�i� l�,�a�� �>-
/�' �suY�c� � /�
��� /�rCs��/� ?'`�ir� Q�� �hsal �Ce�
;�`�cfi�ii�h �o �/�' /y�f.�� ��/ o���� �-, wc
l�'`� �o`rsfv���is,y c't'arGf�' ��.�l�i- y-vG,%y
� �-rar�s< �c��o�syr �r�.r �/s'�-� .E� � ,
i
- — _. . -- - - - _ _ -
_ _ _ _ - - -- - --
- - —
Mail Permit to: �h��- i- � �/� /� D//r'/'f`—
S!GLe, �..� �� ' � �G i`L¢�. .
What is the current use of the Building? _T -,
Materiai of Building4 �d���4'�welling, how many units? �
Will the Building Conform to Law? /�� Asbestos7 �
��
Architect's Name
Address and Phone � �
�- Mechanic's Name "`"'� � �a ���� �
Address and Phone � S ���''`�" �r�v� ,�1� �� ti ,
Construction Supervisors License# D� .3?� _HIC RegisVation# /� f yS'7
Estimated Cos of Pro�ect�L7 S�� Pertnft Fee Calculation
Permit Fee$ �9� � Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
M 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 build to the above stated
specifications. Signed under penaity of perjury /�
Date��� ��� � �
�
�
�
� � � � �
� N . � � �
r �
� ��� � �� � � � � � �
C /Q
O. � � ,� � 1 � � .
� `" � �' �0 �+ °q � � S �
� � -
o �r � a _
E- a � ° `�' �, � ° 9 � � �
� u � ° o u � �
� $ L� � �+
o, � u ,, a a
_ - � _ � _ � _ � �— -- - --_— -_— __- -
,
, CITY OF S1�T.EM
;r' PUBLIC PROPERTY
DEPAtrrMF.N'r
��rat,�•, t3ow..varicsc�a'n�.T�sn�.r.�wss�xcs�nsotv7o
'1��:97b7�S-9S9S�Fnx:97b7ia96i�
Construcdon Debrts Disposal Aftidsvit �,.
uiae0 foc all demoGtioa and mwvation work) ♦
(�1 .
�n accordance with the sixc6 edition of the State Buildia�Cod0.780 CMR sation 111.5
Debris.aod the Provisions of MQ.a 40.3 34:
BuiWina Pecrnit M is issuad ait6 the coadidoa eha�t the debris reaultin�8mm
this work shaU be disposad of in a propaly liceased wa:te disposal l�cility a�deRned by MQ c
lit.suow.
The debris will be transpcRed l�"•
.�l�G�id� C'os�S�
(n.m.oehwta�
The dcbris will be disposed at in :
�/��e��� �a
- (namt o!Pacility)
(��� ../.�.� /��''�ev 'er�/j.�
t,�..or����ry)
s�,�or�,u� <<y o�
/d—'��-�C9t�
eu.
� - /
;�a.,mr.,wc
�•
CITY OF SALEM
��, , PUBLIC PROPRERTY
DEPARTMENT
KLN8ERIEY DRISCOIi
MAYOR
120 WASHQVGTON$TREET�$ALEM�MASSACHUSETTS 01970
'I�L•97&7459595 �F�VC:97&740-9846
Workers' Compensation Insurance Aflidavtt: Builders/Contractors/Electricians/Plambers
Apnlicant Information Please Print Leaiblv
. NazR@ (Business/Organiisuon/[ndividual):_L�TGL//�P� �O/��(/C7-'JdN
Address:_�.S .5'ri�2�t � :Dd/v�
City/State/Zip: ���1 Phone #: '17�r —�'r��' — �� 7 3
Are you ao employer?CLeck the appropris bo • Type ot pro)ect(required):
1.� I azn a employer with 4. I am a general con�actor and I
employees(full and/or pazt-ame).• ve hired the sub-contractors 6• ❑New conshucHoa
a sole proprietor or pazmer- listed on the aaached sheet = �•�R��eling
ip and have no employees T'hese sub-contractors have 8. � Domolitioa
working for me in any capacity, workera' comp, insuraaca 9. � Huilding addiaon
[No workers' comp. insurance 5. � We aze a cocporation and its
required.) officers have exercised their 10.�Elechical ropairs or addiHons
3.� I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself. [No workers' comp. c. 152, §I(4),and we have no 12.Q Roof repaus
insurance requiredJ t employeea. [No workers'
camP• insurance required.] 13.❑Ot6er
tAnY%PP�i�t that checks box pl mwt alw fill out the uetian below ehowin�thejT wuritas'compwea�ion policy inPortnatioa
Homeoxvm who submit thit affidavit indicating they ue doing all wodc md thm h"ve outaide eantraeWn mun eubmit�new afTid�vit indieatinQ eueh, .
=Contracton tdet check thi�box mwt anaehed an addiuonsl sheet ahow'vig the name of t6a subcontrattoo end the'v worlcen'comp.poliry infortnadoo.
/am an employer tyat Lv providing workers'compensation insura�ce jo�my employeex Below is the pn(icy and fob slte
injormatioa. /�� /�
Insurance Company Name:_ � 4V �/
Policy#or Self-ins. Lic.#: �.S .� !�U{� "'"'� 3� sp,��vaGon Date: �� — �-- (�
�
Job Site Ad�ess: �q'�
` City/Sbte/Zip:
Attac6 s copy o[t6e worken'compensatloa poll y declaraHon psge(showing the poticy number and :pirat on date�
Failure to secure coverage as requimd under Secaou 25A of MGL c. I52 can lead W the imposiuon of crimina!penaities of a
fine up to$1,500.00 and/or one-yeaz imprisonment,as weli as civil penalties in the form of a STOP WORK ORDER and a fiae
of up to$250.00 a day against the violawr. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fot insurance coverage verification.
i ao nereay cem�y unoer the pains and pena/nes ojperjury that the�njormohon provided abave is dut and conect
Si natur • p � ; — �—b
� Phon
OJf7cid use on1y. Do nnt write in rhi.t areq to bt complefed by ciry or tnwn o�ciaL
City or Town• PermiULicenae#
[ssuing Authority(circle one):
1. Board of Health 2. Bullding Department 3.City/fown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Ot6er
Contact Person: Phone#•
Information and Instructions ,
Massachusetts General Laws chapter 152 requires all employecs to provide workers' compensadon for their employee`s.
pursuant to this stacute,aa emp/oyet is defined as"-•••every Pers°n in the service of another under any contract of hire,
express or implied,oral or writtea"
An employer is defiaed as"an�vidual,pazmarslvP.associadon,cocporadon or other legal endty,or any two or more
of the foregoing engaged in a joint entecprisc.and including thc legal rapresentaaves of a deem lo ees.t Howeves tho
receivu or tcusue of an�°d�n��p�°0�p'���aon or o[hec legal entity,employing p Y
owner of a dwelling house having not mon than thm apaztments aad who resides therein,or the occupaut of the
dwelling house of another wh a empio�pe�re��1�II�ca°��of such employment be de med to be ane mployer.'�'
or on the gounds or buildinB PP
MGL chapter 152, §25C(6)also states tha���every stste or locallieensing ageocy shsll withhold the issuance or
renewal ot a 1[eeax or permit to operate a busineu or to comtruct buildinSs in the commonwealth for my
applicant w6o haa not produced scceptable evidence of comptiance with the insurance coverage required."
Addidonally,MGL chapcet 152, §25C(7)staces"Neither the commonwealeh nur anY of its poliacal subdivisiuns sha11
• enter into any conaact for the performance of public work until aaceptable evidence of compliance with the�n��*a^�
requirements of this chapter have b`een presented w the contracting authoriry."
Appticanb
Please fill out the workers' compensation affida�it compleuly,by checking the boxes that appty w your situation and,if
necessary,snPP1Y suiacontractor(s)name(s),address(es)and plsone number(s)along witFt their cettificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than ih�
members or partaers,aze no�re4�ed w cazry workera' compensatian insurance. If an LLC or LLP does 1�ave
employees,a policy is required• Be afi'ised that this affidant maY be gubmitted to the Department of Indusa'is1
Accidents for confirmation of insuranoe coverage. Also be sure to sign snd date t6e afiidavit 'fhe affidan�S�ould
be retumed to the ciry or town that the applica srio�� �������fY u�e��ed� ����t of
Indusuial Accidents. Should you have any que 6
compensadon policy,Please call the Depamnant at the number 19sted below. Self-insured companies should enter cheir
��';r� ++ce license number on the a ropriau line.
City or Town Ofticiab
Please be sure that the a�davit is complete and printed legibly. The Departrnent has provided a space at the bottom
of the affidavit for you w fill out in the event the Office of Invesagadons has w contact you regazding the applicant.
Please be sure W fill in the pe:mitllicense number which will be used as a reference number. In addition.an applicant
that must submit multiple permit/license applicaaons in any Siven Yeaz,need anly submit one affidavit indicating�c�or
policy informaaon(if necessary)and under"Job Site Address"the applicant should wriu"all locations in ( �q'
town):• A copy of the�davit 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 fite fo�rlfu�p�[*��i oot elated to any b iness or commerc al venhue
yeaz.When a home owner or citizen is obtaining P
(i.e. a dog license or permit to burn leaves ete.)said person is NOT required to compleu this affidavit
The O�ce of Investigarions would like to thank You in advance for your cooperatioa and should you have any quesdons,
please do not hesitace w give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
D�pattment of Ind�stcial Accidents
OfHce of Investl�ations
6pp Washiagton Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-8T7-MASSAFE
Fax#617-727-7749
Revised 5-26-OS �y�Wy,meS3,gOV/d18
� - � -----'----- "'�� �-----_ \, �
. �
----_--`---�-------.�...... �� .
. �
� i
� ��r.�i �rrr.>c � � .
. � - , �YNE,. f,'AL� .
. � �l'% PRf?rr„tos^i �hID S`ioRt',<-E .
- � i �'.,�,i� i . .
. . IJ_,_..�.. ._._...f . _ _ . .
. "__�_.___ l
, � . We.w cta�F�k�e rec�,
� ' Ne_w o��-0ic1�r apc'rx-it . � .
_ � : Ni'�W v^Se^L'ctcF f��4tiwc� .
' . Pl_'la� `7�4S�Cr '
�
. . . _.....> .. ..- FTLU,`"�`"�y i
J
, ':.Y 5'_, :>`I C± (`N S C"!.
' . . tyrF�Sn�wf� Ant'f Vf���'R � .
i
� !7>"t4 k'�c-.'+^ � +
�
— � i.1
. . � . 13., {. .
.� - � i
. •�'y9 R_.'1. � I
� ^lAi:.. ' � .
, �
�
� 4
N
._ �l`s:FS'`rn'j �; . . , f_'--.— . , n z
�r,:u�.�Ky + t�1r. �__ l-rS�54.�.nR I � a
l.RN9tW�)6 � � �
_7 �
_ ._ --- �. _ � , ; ;
� /�,'`L- � ' � .�i ��" I !
atr���b�- � � � � .
ceo+.,-c,�- X �
_ _. ._' .'._.� I
� �' �t ��_ {'�- � -� �
,, - _ � ' �; /�� /'
; �
� . � �i _� .....-I_1���,�_ _ —V � f �__� 'I.
� I 1
\ �.. 1� _ "_ J . __T_ _ i . ryr_W C(OSC�' � .
L}a t.p. . .. i i ' ti H rC c� i
(A � 3' — . �' ._.. .i l\ I'
�� Ut l.�l V 1� �41 . . . �
� f �i a v
� _ �� 5��2��` �_ __ _ . _ ���-�,. _ _ � , ,�. ..��.
; _
' -------•-- ' ,a r
.. _ _ .... ._.. . . . � ...___ .... . ._._.._� . ,. 'nf -
.�_. _. ...__ .. .-� .. - -- ,.,
c,�a. -_ �� � � � :aris�%��r,: I �
_�. _., � -- -__... _._ _____ __ _._� .. _..- - _�' �
1_ .._ __. ,._ t ;-n�:- K,N: i
. i Y/i-L+l"tT��N I
.. . i /.�u'v �'OftreGE 4
�_..._'__'____'_"____"'___'__""_"'___"'——'_.}
. . �ob S f '�- !�/ �7 0%1..-��/!"F, s:/P j�
� . fJ/+t?lLHC�-a� = �',`JTIG;r'�r-?;'_'�'rf'.'S_,�;;�1.._.fu7.J
_ . ���L-. . � u_i� . /J�li�c°'�.'�`�/ �:�_�:�rf,i� I
/�y� � ." 1_.rj'.
I
�
� _ . . _ _ . . � 19 . \
A. . . . . . . . .. i _ . . . . � . y _ ,
� . , �xsisrvnia . . . . ,. . . . _ . _ . .
. . . " . ' y-'KNEE�'WNLL. . ..__. ._ . . . _.. _ . . . ., . . . . . ... .
� � �� PART�Tronr ,�.ND sTo2PCaE .. . � � ,
. . .. ._ . . . . . �� �� . . _ . . . . . . ._ _ . _ . . . _ .
. - . . . . . . � . _ .�.9 ee� �__ . . . . . . _ . - .,_ . .
. , . . » . � .. . _ . ._ ' _ _ .. .�. , . - , .. _ . . . , . . . ,' . ._ : . �. . . . . _ .. , . . .. . � . _ ,
�
. .. . � . .- . . . �. . . . . . . . . ..
, ' . �NcwGLOSeFa.e0. � .
. . _ - � . . nfe.w ou}lefc to codc . . . • . . .. .
. yJew restene.cf 1��4+i�n,c� .
. . • . • .. . NEw Plasler. . ' - .. . - . - .
i � .
Exsrshlvc> FrL�-��w5 �. , _ _ . . „ . .
• • , ' . .. - � �7cs�sHwG �wSUL. . . . � . . . . �
� . � . . . • �YrtSl-iwG ?oa'/ 'vRPoR. . . . , _ _ . ..
Srtr�i e�,
.. . _ . , v s _
- - '.0 �? �
tiaw ,
� . . . _ n . . 1 "�N � M _ . . � i. . * .
� VM
. . , T ._ .. .. . . � _ ,�1�Q'� " " " .. . . . . �. . . . _
V
. � . . . . - . � � � � . . ._ . . . _. _ _y . � . ..... .. . .. . . . .
�sis t�.s5 . �� Q
� C
Fru.w�..y r IN��.. .. � . . . �xS�sFnn4 � . . . ... ` _ . . _ . . ... . .
/� .... , ,f. . _ . ... LANDING . . . . . . . . . _
. ... ' .� " ' � � �` . ,. .._ ._ . . _ . O 1_b . . . _. . . . . . ' . ,
P \nS6r _ . . . . b�y _ _ _
. , . ._ _. � . . . . � ce+��u-� � . .. . . . _. . . _ . . . . . � , —� . --. . .. _
t.� l
/ �
_� . � � _1/\,f\i� — —'/�. �\--
, . ; � .._ , . . _
._ . . 11� - . � . .. ...,.. . _ . , Ne�J C(ost+ . . . . , � _ . . . . _. .
�rC a r
- ` .Q . . _ .. . . .. . .. , _ . . .
. . . � . . , . ' _ . . . .. Do o ? `a�e �. ... , , ____ _ . . .
. _ . _ .. _.I 5�0+°'�` \ � . . _ .. . � 'x'-o� �,_;,�_.� , , .
_ + . Y _ _ oW , _.
. . tGi oQ �,u0 'Fvs/S�i�rvG � { ' .
_ .. . _ . . . . . _..� .—_. . ...__. . .. .. ... _.. . . . . . �11eG4lIFLL . . . . . . .
' P/F2 Tf T�o N �
. : . 4 _ . ...� " _'. .. . . _ _.. . . � � . . _
' � pNo �7'ORh6E , . -� �- . .. .
_ - - -_ ._ _ . . . . _ :. _ . Job s�f-e ' �v Ar>E2.c� w+�Y
, , . . . . . , , . �'O.vl/1H�cTo2: .�/fTUG�PPE!'OiYS"�TRuCT/aN
, ' _.. .. _ _ �. _. _ . . . �/ec¢i�ci�w : .�TI'RZ3Efl"!/ G�/�C77Z/L
_ . _... _ _.� . . . r _ . . . . .. _ . . � /y � i 1_0.� . . . _ . ...
. . _ . .. . . - . . . . . _ . ,. . _. . � . . � . . _ . .
�. . .. . . .+ - . ... _ _ .. . .. . . . .. . . . . . . . .. .. . . .�
� e n. . . . . . _ , . �_ . . _ . . . . . ..
' � -------- `9, --- �.
� V , . .— -- ------_ �
- I ,er��sr��rc.;c - ;
. � ' . KNE£-� WrPLL ' �
� � :)%' PPL,'..`r�v, F.N� ='[-oai:,c,E � .
� � ^ „��.,
�,0 A� li
� �J_._.�_. �,....._i . . . . _.._..__. _..._ .. .._..__.__.— .
� .
I
. Wf1.J C t!1.$f.i Cl ffL1_ �
. . PY2�.0 �V°FIe4S` '!�Cn<I{ n . . , - ' .
- yJc� v�ters:e�� F��4tr.�.q !
- _ _ � negw Pfas4'r
. . . _._._y..;,.r �:(.Wvrny �
J
� .....5'l�:;ni�, ('NSckL� ,
. � . ,.ty�f4+�wf� �o:-b' � VI"'upR '
. :;tiRF+�!;,r ! '
u � �
_ +�z
,�..,
�nG - i
- � _ `�9'm.r� 1 I �
f� q!��`l - .
N
V
l
♦ �
µ
.. fi.j s��'N�� � �.,-7 . " . h R
i'
Fr�,r,�K + t�VS. f � � !_yS,��.�.nR � � �
. `1 . �--- --__— .. I
LCiN4��`1G . �
____�_
l.- ; o ,'-�;` � i
�\�� ,- �
�' -� _ ' i �_� ��>
� � ��,, .- i
����,F � � �
t - YGa✓ .. — .._.—_._.. � _.. ._' ' I � �
f✓o I� � � —1 '_i �
, /� ;----r!-- � , ----�-1 � I
�� � -- i � --� /\.�'ti— — —"''`� `''`�,-- '
_: .._ i � _s .
� i. A. --i - n�e�5 ctose+ � � .
� L °' � ' I
�� . � � . _ =; If rca �
i �� ��
l7p I ' D6c+� ' v�P - •� v I .
�
�` � � � � ._"__'___ _ '_. _ __ .. �2...�.'/ . _. ... � � .
i �_
, I S4o. `1 1 �. a TC, , I
�� -- _ ,
_...._. -- - . __ _ _ _- ---._. .. _ __ _....._.. �. . _,.__._, ._._�__r �ns• i
: � i � I �
-G� :J,:] f. ..> , i'i'Si51rrvG i
1__ ---------�._ ______ _---- — -. _ . _ _ .__._,� ___ _��'
t ,
.r�nr? u�M�L �
� i YA2rfT�eN . .
/-�vv �l'oan'C�� �
— — -- �ob Si �. ��/ �/1'l<"�'r''f' �✓�?Y
- i Oi+r.Y='i-t�iC�� ,-�'-�c' `i-?.:-'—!'�Jl7iS-;'.��_'i�%cr3.�
. {/�'_-.'. ... .,._i� . ��hCjE�4�J {f'- !7C1.iL.
� �;y .. �- 2-0,.