34 BELLEVIEW AVE - BUILDING INSPECTION (3) ,�
�' _ � The Commonwealth of Massachusetts
�� ► Board of Building Regulations •rnd Standards PC)R
� ,n MUNI('IP:\I.i'll'
D ,,�',� ' Massachusetts Stat� Building Code. 78O CMR, 7 edition ��y�
�' Building Permit Applieation To Construct. Repair. Renovate Or Demolish a Rrrised Juawu.c
One- ur Tx•o-FnrrtiJy DK•rlling �� �����
This Section For Official Use Only
Building Permit Number. Date Applied: G Q
Signature: 6/L q/��
Building Commi� siunar/Inspector uilJings Dat��
SECTION 1: SITE INFORMATION
1.1 Property Adc�ess•� 1.2 Assessors Mnp& Parcel Numbers
�(.) �S[�tl�dayr �vCi
I.la Is this un accepted s[reet'?yes_ no_ Map Number P:ucel Numher �
1.3 Zoning Informadon: 1.4 Property Dimensions:
�G,��f 0
Zoning District Proposed Use Lot—�lsq fl) Frontage(ti)
1.5 Building Setbacks(ft)
Front Yard Side Yards Re:u Yard
Reyuired Provided RequireJ Provided Required ProvidcJ
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone In[ormallon: 1.8 Sewage Dlsposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposul system ❑
Public❑ Private❑ Check if esO
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner� f Recor��nv 3� Q�,V�,� � �G,�
YVtc„� t�
Name(Pnnt� AJdress for Service:
�/v�,�� �� G� 7-�(1 �-77�
Signamre Telephune � �
SECTION 3: DESCRIPTION OF PROPOSED WORK�(check all that apply)
New Cons[ruction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AI[eration(s) ❑ Additiun ❑
Demoli[ion ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: �.�i«1 y' ��G�•/ �� 3� �''�'�S`�
�- �L� Guv' <r a(� La7'—
�f o f- a-.h �.�i� FrvP2�+-� 'r��
SECTION 4: FSTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofticial Use Only
[tem (L•rbor and Materials)
1. Building $ ��'OCJG �• Building Permit Fee: $ indicare how fee is dztermined:
O Standard Ciry/fown Applicatian Fee
2. Elecvical $ �0 ❑Total Project Cost� (Item 6) x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ Lisr.
5. Mechanical (Fire $ Total All Fees: $
Su ression) � q''
� Check No. roo� Check Amuunr. 3 Cash Amuunt
6. Total Project Cost: $ � GP�(J aid in Full ❑ Outstanding Balance Due:
f
� �� 3J I
SECTION 5: CONSTRUCTION SERVICES
5.1 Llcensed ConstrucHon Supervisor(CSL) �, $ $g3Z� C 1 .
VV�,/,�� �(�.ti�j License Number Ezpirotiun Datc
Namc of CSL�- oWcr List CSL Type(see t+elow)
nn,u.Tl ��`2�.v
� T Descri lion
9dJre� u aC�` �� �� Unrestrined lu to 35,000 Cu. Ft.l
� �� � Restricted I&.'_' Fumil DHrllin
Signa��u/r\e>_�� M Masun Onl
RC ResiJential Ruulin Coverin
Telephone WS Residenti�l WinJuw �nd Sidin
CC`Z ���.. ���['� SF Rcsidential SoGd Fuel Burnin A �limicr Instullatiun
D Residcntial Drntuliti�m
5.2�R/e�is�ed Ho��mp�ovement Controctor(HIC) ' (� Ct��
�l
HIC Co pany Name or HIC egistrant ame Registration Numbrr
3� B�G� v"�,. �v S4 l r,�^�
naa«55 n��
`j I���7 ZZy� Expiratiun Date
Signamre Telephone � �
SECTION 6: WORKERS' COMPENSATION INSURANCE AFF/DAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure tu pruvide
this affid•rvit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... � No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� 'V V1�' � , as Owner of the subject properry hereby
authonze� rN�-. C� [o ae[on my behalf, in all matters
relative to work authoriud by this building permit application.
Si nature of Owner � D•rte
SECTION 76: OWNER'OR AUTHORIZED AGENT DECLARATION
i, �'J ,as Owner or Authorized Agent hereby decl•rre
that the starements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalE � n
En/�, f� G( I� �t �i�i
Print Name /' /Gl���^j
�� � K
Signamre of Owner or Au[horized Agent Dare
(Si ned under the ains and nalties of r'u
NOTES:
1. An Owner who obmins a building permit to do his/her own work,or an uwner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access ro the arbitration
program or guaranty fund under M.G.L.c. 142A. O[her import•rnt information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and 110.R5, respectively.
2. When substantial work is planned, rovj�e the information below:
Yotal floors area(Sq. Ft.) � J (including g•rrage, finished b•rsemendattics,decks ur p��rch1
Gross living area(Sq. Ft.) Habitable nwm rount
Number of tireplaces Number uf bedrooms
Number of bathrooms Number of halt%baths
Type uf heating system Number of decks/porches �
Type of cooling sysrem Enclosed Open
3. '"Cotal Project Square Footage"may be substitured for'"1'u�al Project CosP'
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142-10
1� 610-0 � 1198 �13-0-0� � 19-1-12 � 22-2A I 260-0 T7�
1-0-0 &9E 3012 4N-2 1-2-107-2-00 417-2 3012 y9.8 1�.p Scale=l:5].8
CamEer=SH6 m
6x8=
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19 �
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1� 12-0-0 �
� Z 12 y`�
� IW
5�4 16 15 1< 5�J
&B= W12= �_
610-0 I 191-12 � 2600
610d 1238 &10-0
q�reorcse�s x, : �z:o-�ioo-z-s] [s:eaysassL�:o-aoEage] �e:eayeass�,�iz:asia,o-z-s, ia:o-ae,a-a-o. �s:as-e,o-a-o
SPApNG: 2-0-0 SPACING: 7-7-3 SPACING: 1�0 SPAqNG 2-0.0 CSI DEFL in (loc) I/tlefl Utl PLATES GRIP
LOAWNG(psn LOAWNG(ps� L.UND�NG(ps� p��Inaease 1.15 TC 0.70 VeR(LL) -0.4fi 7416 >666 360 MT20 197/1
TCLL 42.0 TCLL 52.5 TCLL 63.0 �umber Inuease 1.15 BC 0.55 Vert(TL) -0.78 1416 >394 240
(Raof Snovr-42.0) (Roof SnovF52.5) (Roof Snwr-63.0) �P Syress Inv YES WB 024 Morz(TL) O.W 12 Ne Na
(Gmund Snox�60.0) (C+mund Snow=75.0) (Gmund Snovr-90.0) �e IRC2003lTPI2002 (MaAmc) Nfirttl(LL) 0.19 74'IB >999 240 WeigM:7781b
TCDL 7.0 TCDL 8.8 TCDL 10.5
BCLL 0.0 BCLL 0.0 BCLL 0.0
BCDL t0.0 BCDL 12.5 BCDI 75.0
LUMBER BRACING
TOP CHORD 2 X e SPF 79WF�.7E'Fxcept' TOP CHORD Shuctural wootl shealhing Ciredly applied or 449 oc purlins.
47 2 X B SVP M 23,7-10 2 X 8 SVP M 23 BOT CHORD Rigitl oeiling Ciredly applietl or 10.40 oc bradng.
BOT CHORD 2 X 8 SPF 1950F 1.7E
YVEBS 2 X 4 SPF 1650F 1.SE
REACTONS (16lsize) 2=1883N38,tY-788310.38
Ma�c Hoa 2=529(baE case 7)
Mm�UpliR 2=678(ba0 case 9),tY�78(loed case 10�
Maz Grav Y-2145(loetl mse 75�,12=2145(loatl case 16)
FORCES Qb)-Ma�dmumCompressoNMa�tlmumTension
TOP CHORD 1-2=0/80,2-7 7=32 2418 31,117=3013/837,3-4=2fi24O07,A-78=2578/717,&18=2497/773,519=1807885,
6-79=1fiO4l/U8.67=350/1623.7$=%i11623,&20=7604!/08.&2�1801/685.421=2497l713.70.21=2578f771
,1471=2624f/W,'It-22=30'13/837,12-22=3224/837,72-73=0/80
BOTCHORD 2-16=-BOBf2585,1i16=207/1808,1475=207/1808,12-14=5322585
� WE&S 6-8=3682H258.516=137A232.414=13flH232.&76=1165I505.11-14=1165/508
N07E5 (76)
1)WirM:ASCE 7-02;120mph�24in o.c.;h=35fl;TCDL=2.8psF:BCDL�.Opsf,Category 11;E�C;eritlosaU;MWFRS gade entl zorre
and Gc F�Geria(2)-1-0.o to 2-0-0.IMerior(1)z-0-o M 10-0-0,Erteriort2)10.0-0 to 16-0.0.IMeriort�)�s-o-o ro z40-0.ExterioKz)
� 24-0-0 to 27-0.0 zone;carNle�rer leR and rigM exposetl;LumOer DOL=1.60 plete grip DOL=1.60.Tliis Luss is tlesgnetl Tor GC for
merti6ers and forces,aM fw MWFRS fw mamons spadfied.
2)WiM:ASCE 7-02;t30mph @79.tin o.c;IF351t;TCDL=3.Spsf;BCDL=S.Opsf;Calegory II;Ezp C;eruiased;MWFRS gabla erM and �y�
GC E,neri«(z)-i-o-o ro z-o-o.iMe�iar(i�aao m iaao.ezrerior(z��o-ao m is-o-o.trnerior(i)�s-o-a m 2a-o-o.�ctwrortz)zaao �,ZH�F A1A`e9
M 27-0-0 zone;ceiNlever leR antl rigM exposed;Lum6er DOL=1.60 ptate grip DOL=1.6�.T�is buss is tles9netl for C-C tor a3� Cy
memtcrs antl(oices,a�M for MWFRS fw�mons spetified. � �',p�,
3)Wintl:ASCE 7-02;148mp��$16in o.c.;h=35fl;TCDL=62psf:BCDL�'i.Opsf;Category II;E�C;entlosed;MWFRS gede erM aM F STEPHEN W. ^,
GC Exleriw(z)-i-0-o to z-0-o.Imerior(i)aPa to to�o-o.Ezterior(2)taao m is-ao.Imerior(1)16uo to 2a�o,Ezteriort2)24uo B �'
to 27-0-0 zane;faMilever leR antl ngM e�osetl;Lumber DO1=1.60 plete grip DOL=1.60.This huss is tlesgrred for C-C Tor
mernbers antl foices.arM for MWFRS fw�eadions specified. NO.31927
5)RaoF tlesign snow loatl has Ueen retluxE lo amouM Por��emW srww):Cate9aY II:E�C:Fulty E�ry.:C1=7.1 �O,i.'9EGISTERE��a��e
6)Unbalancetl snow loatls�aVe beem m�siCaretl tar lhis design. � FSSlONAL EN�\
7)This Wsa hes 6een designeE for greater W min moi Irve bad d 76.0 psF or 1.00 times flffi roof loatl o(42.0 psf on oveihargs
noncoriwrtent wilh other tive batls.
e�rn�s wss nes eeen aesiy�ed as��iec sea.isos.a.i.�i osa rea�mon,mr munipe oVe waas. April 24,20
n designetl tor a 10.0 psf boltam chord live loed rronconcuneM vrith any other live loeds.
� WARMNG.Ver(tydu(gnyvramctmaanQRPdONOTFdONTHlSANDIM'WDEDDI/TBRASFFdlSNCBPAGSlfR-f4TJBCPOAEU9& 10.515N.OUIBfFUIIy. �
SUHe0900
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APP�imWiN ot tleSqn peanen�as mid proper"vicarpwalon ot rnrtq�w�en�o re5pornR�i6ry ol bWtlbip desipna-mt INx tle.tlgner.Brocl�q s�ovm
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NOTES (16)
70)This huu requires pate inspe�rion per the TooM Courrt MeMad when t�is tnus is tliosen for qualdy assurance inspection.
11)'This lruss has been deag�tl Tw a li�e loatl of 20.Opst on the boLLom diad in all ar�s where a reUargle 360 tall by t-0-0 vriEe will fil helween Me boHom chwd arM
airy ather members.
12)Ceiling deaC loatl(5.0 ps�on membeKs).56.&9.6-8: W�I dead loatl(S.Opsfj on member(s).576.414
73)Bottom chord live load(40.0 psn end atlditional boltam thord tl�tl load(5.0 ps�applietl only M mom.t416
74)Pim�iEe mechanical connedion(by others)of truss to bearing plate�apable oF withslantlirg 678 Ib upBR at jdnt 2 antl 6781b uplift at joirit 12.
75)This buss is Aesi9rred in ecmrtlance wilh the 2003 IntemaGonel Resitlential Code sedions R502.11.1 aM R802.701 antl referenced slantlaid ANSI/fPl t.
16)D�awing p2pa2tl e�Musrvely tot manufaGurirg Dy Wootl Stn�ures Inc.
LOAD CASE�S) SYarMartl
AWARMMG-Ver�(yQu(9npvrvmelu'veMNE.fONO]890NTHISANOIACWOEDMITEHItBTFRE�K`EPAOBMII�9093BC➢ONEU3E ��5�.�fFdly, �
DmgnvaftllaineoNyv.iMA4Takcon�clwzlli'stletlgno1w5e0oNyuponpamerefaszMwn.antlkManFdMtlualWiQlrgcvrWorient. CMalMretl.MOfi901] �
nppGcadllN of tleilgn pamrentaz rnW pape. i�cwporal'nn ot cortpo�nirs�pomb5ly af W&Ihg tlesig�-rot hus deSlgm.Bracirq sfwv.n
kforlakmisupportofmdMdualv.ebmembasoMy. n�fiorwllemporaydacNgtolnswesbbLNaurirgconmrctun6ttrerespor�drMotme
eieclw.Addifiorwl prnnar�enf ba mg of Mre ova�l z�ucMe k IM1e ie5ponf0PN of Me buid'vg desprier.For geM a19ulUmice regaNUp MTek�
��k:anon awrN�omra.:�aoee.��+m.ere�eo�m,a bor�e.�nm aw/��W�oaeao.o56av a�ecv�e�e comv�.��
Salelr INmna9on awiloble M1wn T�PbM IrtaMiAe.5B3 D'Orroho Drt+e.Motlean.WI53I19.
� i � CITY OF SALEM
i
, ,,. ,
ROPRERTY
�;� � ,� 1�UBLIC P
;, ��`
�"�""� DEPARTMENT
F:I)115FALEY DRiSCOLL
M`�YUK I?O W:\SHINGTON STRBF.T 1 SALF_N,M:\SSACFNti['I"CS 01970
� T[�: 978-735-9595 � F�x: 978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4pplicant Information Please Print Le¢iblv
NRrile (6u>iness/Organization/Individual): 1 �'�"�L� � G a✓��/�
Address: 3� UCr�([r'� v✓ ���
o(�?� 6'!7-��7- r7
City/State/Zip: Phone #: �
Are}'ou an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
�iployees(full and/or part-time).* have hired the sub-contractors
2. I ssm a sole proprietor or partner- listed on the attached sheet. $ �� ❑ Remodeling
ship andhuvz no employees These sub-con[rac[ors have S. ❑ Demoli[ion
working for me in any capacity. workers' comp. insurance. 9. � Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required�.] officers have exercised their 10.� Electrical repairs or additions
3.� I am a homeowner doing all work � righ[of exemption per MGL 1 1.❑ Plumbing repairs or addiriotis
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] 1 employees. [No workers' 13.0 Other
� comp. insurance required.]
'Any upplicant that checks box#1 must alsu fill wt thz section below showing their workers'compensation policy information.
1 hlomeowners who submit this aftidavit indicating they are doing all work and Ihen hire outside contractors must submit a new a�davit indicating such .
�Contractors thal check this box must a[tached an additional sheet showing the name of the sub-contractors and�heir workers'comp.policy infortnation.
!u�n un e�np/ayer thut is provrding workers'compensation rnsurance jor my eniployees. Below is the policy and job site
ii�forinufion. .
Insurance Company Name: �i
Policy#or Self-ins. Lic. #: Expiration Da[e: i
Job Site Address � City/State/Zip: ��I
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ',
Failure ro secure coverage as required under Section 25A of MGL c. 152 can lead[o[he imposition of criminal penal[ies of a ��
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine �
of up to 5250.00 a day ugainst the violator. Be advised that a copy of this starement may be forwarded[o the Office of
Investigations of the DIA for insurance coverage verific�tion.
/do hereby certijy under tbe pur�s.unJ pewukies�jperjury d�ut the injornrution provided ubove is true und correct
Sie�ruure� � Date: �/��10�
Phone�:
OJ'ficiu!use on/y. Do not ivrire iu 1Gis ureu, !o be completed by city or�o�vn officiuL
City ur Town: PermiULicense#
Issuing Authority (circle one):
1. I3oard ot Health 2. Building Department 3. City/'fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
II. _... .._. .. . _ .. . ..
Information and Instructions �
Massachusetts General Laws chapter l�2 requires all employers to provide workers' compensation for their employees.
Pursuant to this stamte, an enrployee is detined as"...every person in the service of anuther under any contract of hite,
express or implied, oral or written."
r1n employer is dzfined as"an individual,partnership,associatioq corporation or other legal entity, or any[wo or more
of the fbregoing engaged in a joint enterprise,and including the legal representatives of a deceased einployer, or the
receiver or austee of an individual,partnership,association or other legal entiry, employing employees. However the
owner oY'a dwelling house having not more than three aparhnents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,cons[ruction or repair work on such dwelling house
ur on the grounds or building appurtenant[hereto shall no[because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every s[ate or local licensing agency shall withhold the issuance or �
renewal of a license or permit to operate a business or[o construct buildings in the commonweal[h 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 commonwealth nor any of its political subdivisions shall
� enrer into any contract for the perfonnance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes tha[apply [o your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certifica[e(s)of
insurance. Limited Liability Companies(LLC)or Limi[ed Liability Partnerships(LLP) with no employees other[han 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
Aceidents for confirmation of insurance coverage. Also be sure to sign and date the affidavik The affidavi[should
be returned to the city or town that the application for the permi[or license is being requested, not the Deparhnent oF
Industrial Accidents. Should you have any questions regarding the law or if you are required to ob[ain a workers'
compensation policy,please call the Department at the number lis[ed below. Self-insured companies should enter[heir
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[o fill out in the event the Office of Investigations has to con[act you regarding the applican[.
Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition,an applicant
tha[mus[submi[mul[iple permidlicense applications in any given year,need only submit one affidavit indicating curren[ �
policy infortnation(if necessary)and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the af5davit 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]icenses. A new affidavit must be filled out each -
year. Where a home owner or citizen is obtaining a license or permi[not re(a[ed to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required[o complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
� please do not hesitate to give us a call.
Che Depamnznt's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
2z�[�zd s-z6-os Fax# 617-727-7749
www.mass.gov/dia
h. � � . - � �J�S /
. , ���401�i] b�nd ��pDO� D��OQ���03a �aQo
Professional Land Surveyors £r Civil Engineers
ESSEX SURVEY SERVICE 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLCYT PLAN OF LANI)
LOCATID IN
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