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35 BROAD STREET - BUILDING JACKET lWendafoe Wsse/te 74520 400/6P4 .1[..0 . I c- iiI� 1 i 1• (1 UhA�r. r, Iq YID - ISI c+ 1 vc,l,b, � 'Lr'J < r 115 fikf � I I . j IDC�fF7TL� f� i W i� rle+J I I i I , 2�r� IToP�� �ti C4 �5 �' i 4k35 ' BUYER: Paul viccica & Helen Sides MORTGAGE INSPEC?10h4 PIAN LOCATED M — iO THE (.�.r_6n r Na r ; .,.,..T Af r �. AND ITS ttR a MS RFRS ) S A L E M MASSACWS_EITS I CEADFY THAT I HAVE I7(/J.IINED THE PREMISES AND THE BLRIDIN0.5 &iOHN DO ( OONFOfW TO TFIE ZONMO LAWS AND AMMDMENM Lc(FRONT� Mr. r REM Do SETBAC� IONLYFVR Of �a' P1❑ WHEIT 004STRUCTED. I fZ m P. CERTIFY"h1AT IRS PROPERTY IS yl=..'"� A"FJ• not IDCATED M 771E ESTABUSiED ►LOOP DEED COMMUNITY OVSISPANEL N0.: 250102 0001BDA� 8/5 /85 Boat - IA()(I LATEST DED OF DIE RECORDS IS LIADE ONLY SIBSEOVFNT TO DIE RECORDED DATE OF TITE LATEST DEED AND DATE NOT INQIIDE VM"NO THE ACCURACY OF hRE DEW DESWIPTIa7 PI+ENa75 10 fTf DATE OF � PAGE _ 302 hRS COMPANY IS NOT RESPONSIBLE FDR ANY IIIDENTURES MADE " CERT. NO. DATE OF THE LATEST D® OF RECORDED. SEah]TT TO THE R£OWDED AFfFNEA"M EULDMOS ARE SHOWN LESS THAN ONE FDOT FROM h1E PROPERTY LINE IT IS AD"SfD PLAN BR. PAOF. THAT A MORE PREOSE SURfEY BE MADE TO VERIFY THESE NEA&lE P OPEF ti41E. PLAN / DATED IM CERTIFICATION IS EASED ON THE Ipp,(TION VEY MA1yaTS Q OTHERS, AlRI DOES .INOT REPRESMT A PROPERTY S'UR ''((,,�i",1 K C f ri THIS CER71FICAPON To gp<IISEb'FDR: O CE PURPOSES OtJLY. -Navaml— e 19. 19 92 . », �' 20 ' O SAS SHOWN'' ARE OT4o BE USED FOR THE. STXBU!PiMENT• 4,. PRQpERTY ONES BRADFORD ENGINEERING CO. COW CITY OF SALEM9 MASSA CHUSF.y'fi'><SU;r SLE i uA yam , BOARD OF APPEAL CLEfthiVS OFFIOc 3 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA 01970 TEL. (978) 745-9595 FAX (978) 740-9846 2001 JUL 25 P 2. 39 STANLEY J. USOVICZ, JR. ' MAYOR DECISION OF THE PETITION OF HELEN SIDES REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT�35 BROAD-STREET R1--�j A hearing on this petition was held July 17, 2002 with the following Board Members present: Nina Cohen, Joan Boudreau, Richard Dionne, Bonnie Belair and Nicholas Helides 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 petitioner is requesting a Variance from rear yard setback to construct a 2-story addition for the property located at 35 Broad Street R-1 The Variances, which have been requested, may be granted upon a finding by this Board that: a. Special conditions and circumstances exist which especially affect the land, building or structure involved and which are not generally affecting other lands, buildings and structure involve. b. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise, to the petitioners. c. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district of the purpose of the Ordinance. 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.The petitioner appeared and represented herself at the hearing 2. Plans were submitted showing the proposed addition to be constructed. 3. There was no opposition to this petition. . t DECISION OF THE PETITION OF HELEN SIDES REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 35 BROAD STREET R-1 page two On the basis of the above findings of fact, and on, the evidence presented at the hearing, the Zoning Board of Appeal concludes as follows 1. Special conditions exist which especially affect the subject property but not the district in general. 2. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship to the petitioner. 3. Desirable relief can 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. Therefore, the Zoning Board of Appeal voted 5-0 to grant the Variances requested, subject to the following conditions; 1. Petitioner shall comply with all city and state statutes, ordinances, codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted and approved by the Building Commissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finishes of the new construction shall be in harmony with the existing structure. VARIANCE GRANTED p July 17, 2002 Joan Boudreau C,�C(v� Board of Appeal 0 c r; n N F3.MJ -O A DECISION OF THE PETITION OF HELEN SIDES REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 35 BROAD STREET R1 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 day date of filing of this decision in the office of the City Clerk. Pursuant to 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 that 20 days have elapsed and no appeal has been filed, or that, if such appeal has been filed, that is has been dismissed or denied is recorded in the South Essex Registry of Deeds and indexed under the name of the owner of record or is recorded and noted on the owner's Certificate of Title. Board of Appeal N c-; m 0 N �C� Ul � N n� m=. w D A CO Salem Historical Commission ONE SALEM GREEN,SALEM,MASSACHUSETTS 01970 (978)745-9595 EXT.311 FAX (978) 740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: 0 Construction 11Moving Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property: 35 Broad Street Name of Record Owner: Helen Sides & Paul Viccica Description of Work Proposed: Repair/replacement of clapboards as necessary. Repair front vestibule. Repaint house in existing colors. All work to replicate existing. No changes in color, material, design or outward appearance. Non-applicable due to being in kind maintenance. Dated: July 31, 2001 SALEM HISTORI L MISSION By: The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work. (J�-, 1232 $ Z<gv The dofBuimonwealth eguIafMassac=1'0NAL SERVICE S CITY OF Board of Building Regulations and tan �dgs Massachusetts State Building Code,780 CMR AA?R)7 p SALEM Building Permit Application To Construct,Repair, enl olisj..a 3 Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: I Date plied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION -I 1.1 Pxoee�Address: IZ Assessors Map&Parcel Numbers 5 b Roq U St l.l a Is this an accepted street?yes—V- no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions:P � 5�i .1te. i Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) } — 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public Ii Private❑ Check if yes❑ Municipal[3On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2. Oityner' Record: p - )e e o ct.. 1*5 1 1 Q-L1 Vlffc l CA SA wl Name(Print) City,State,ZIP 3S . $✓o4ilSf ef ]cF-71fl-IG43 /t[si��se �jwta( �•yo„N No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Buil4mng Owner-Occupied 12'1 Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Descri[[pplion of Proposed Work : �Ci ILIi1GV1 Vo-lnoVgtlr4 SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Labor and Materials Official Use Only 1 Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (RVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount:_ 6.Total Project Cost: $ 9 01 0 6 D ❑Paid in Full ❑Outstanding Balance Due: f`�1 A-1 1_ -Tb SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) M i L H A Et- 2 . 0 O 1 R-V N License Number Exptration Date Name of CSI.Holder List CSL Type(see below) yc' kV(4 T 5 T No.and Street Type Description �,Q U Unrestricted(Buildings u to 35.000 cu. R.) 6 r U l=2 U'y 'm A Q Ill I� R Restricted I&2 Famil Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 976q1?-CkALf Lit p4jukoUse we,sl%}co.COM 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) i t I�USElu21C�kT C-0 1<-Il P1Z1 141C Registration Number Expiration Date HIC Company Name or HIC Registrant Name Li ST Mitt e+l%ckoustwsisl%+to." r. No. Ad Email address� aLyJ VAaol9t� g�tyz ,GU3 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 .......... - No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Ike �pu$e W rt�hf Co to act on my behalf, in all matters relative to work authorized by this building permit application. 4"-Ie" �. 5 rzje5 -+( -( I5 Print Owners Name(Electronic Signature) Date SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is tru nd accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's me(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eoNAps ?. When substantial work is planned,provide the information below: Total floor 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 heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage'may be substituted for"Total Project Cost" Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction ❑O Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire (" Address of Property 35 Broad Street Name of Record Owner: Paul Viceica&Helen Sides Description of Work Proposed: Replace a 616 window with 3 casement windows. No work will be visible from the public way. Dated: October 30, 2014 SALEM HISTORICAL COMMISSION By/ The,homeowner.has the option not to commence the work (unless it relates to resolving an outstanding.- _. violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 W4, Boston, AM 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): THE HOUSEWRIGHT COMPANY Address: 45 HART STREET City/State/Zip: BEVERLY MA 01915 Phone #: 978-922-9963/978-473-4004 Are you an employer?Check the appropriate box: Type of project(required): 1.21 1 am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' insurance.* 9. ❑ Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I L❑plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 must also HII out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees.they most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: FARM FAMILY CASUALTY INSURANCE Policy#or Self-ins. Lic.#: 2001 W7445 Expiration Date: 12/10/15 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and enalties*erj!a that the in ormation provided above is true and correct mature: _ _ Date Phone#: 978-922-9963/978-473-4W Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: IM Massachusetts -Department of Public Safety Board of Building regulations and Standards License: CS-059906 11.-` ,/ MICHAEL R DOIRON PO BOX247 . ; a{-..7 F PRIDES CROSSING MA 101965 Expiration 07/05/2016 Commissioner 1 Office of Consumer Affairs&Business Regulation , iOME IMPROVEMENT CONTRACTOR r i0egistration: 146121 Type: '� � ,;.Explratlon: 32812017 Private Corporatir _;` THE HOUSEWRIGHT COMPANY MICHAEL DOIRON 45 HART STREET BEVERLY.MA 01915 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature r '� .• 1 i. I ; ;. S I f _ - --fib"---- - I.1,P. 3( tivy C 19 YI' - 1.1c+ 1 da.I, 14 .y I�5 (,kI '•: i sF ' \ lvc�h•e�:� r} W i�tCA,a — �! I ' I H 2l2 JT.r--( . \boo T _I I . ._ _. 1�20�,►� ST BUYER: Paul viccica & Helen Sides MORTGAGE INSPEC .90N PLAN - LOCATED IN µDITTs(TI,�hnr Natinn^ 1 hf r g� T� NaIRExs. � ) S A L M M I CERTIFY THAT I HAVE EXAMINED THE PREMISES AND THE BUILDMOS SMWW Do ( ) MASSACHUSE 1 I CDNFDRM TO THE ZONING TANS AND AMENDMENTS, 1.�.(FRONT, SERE, i REM YARD SEIBACIC ONLY OF SS aa,, PP DT� NHFN COISTRUCTFD. I FVRTHFR CERTI 411.TITS PROPERTY IS n0 C LOCATED IN THE HSTABUSrIED ►LDDQ i r.J COMMUNITY PANEL NO.: D® 250102 OOOlIIDA� 8/5 /85 DOOC - lAnr, LATEST DEED OF TFIE RECORDS IS MADE ONLY SUBSEQUENT TD T1E RECORDED DATE OF THE ICIEST DEED AND DOES NOT INCLUDE VERI NNG THE ACCURACY OF TIE DM DaC RIPTOI PAGE - n PMVOJS TO RS DATE OF RECORD. TIIIS COMPANY LS NOT RESPONSIBLE FOR ANY INDENTURES MADE "SMANT TO THE RE'CC11DED CERT. NO. DATE OF THE LATEST DEED OF RECORDED. S"OVM LESS TMAN ONE �� T 1NE IT IS ASDHYgRVEY BE MADE O vENry E FLAN SK PAGE - NOTE, PLAN / DATED TIee cERTETCAt1aN Is a ism aN ii Tori "� vEv uARlmu of oT11ERs AND Does .jNOT REPRESENT A I>ROPOITY SURK�'ti?'";'9 ri ='f -Nn y P nl h P r 19 -_-THIS CERTIFlCATION 10 tlC1JS�p'FpR; O GE PURPOSES ONLY. t'' 92 .�'d 201 0 �AS 'SHOWN,-ARE O7,}'0 DE USED FOR THE. STABU$HMENT. Q ERN LINES �L BRADFORD ENGINEERING CO. CJ.a On,ll ' II::: 1,11-... _1 T-- Me Commonwr:dth ,it Massachusetts fi rlt it Retard of Budding Regulations and SI.uldarJs \II SI( II' \III 1 l eta>sachusrtu Starr IILiIWhig l\tde. 7St)(AI R. 7"' rJition \I j ( � 1� Building Permit :\ppliraiion To Gnistitio. Repair. R:n+,rate Or Dcnxrli,h a I K OH,' irl' ` I I his .Simon For Official Pse Only - t BwlJine Prints Number _ — __—_— Date .\pphrJ: Buddiig C,nnu . ,uiury I1,1sco r of ILuIJmg, Uarr --- .SECTION 1: SI'1'F: IMOR\L\'PION 1.1 Pnri,perh xd4iress: 1.2 \ssessurs flap r Parcel .Nuutbers ICI ._--. nr I •.lap.\uinher Iy 1 I.t h t`'rs ut acicp ed str.. t ors_— ._ .._.. .>< Zoning ng li-A a ntal.ton: 1.4 Froper.y Dimensions: I Zoning Di,lnet Prupueed L'se Lot Anv Isy lit hiomage i fu y 1.5 Building Setbacks lrU it Front Yard Side Yards Rear Yard Reyuurd Provided Rcywred PnniJrJ Rcywird PiuuJ, 1.6 Water Supply: (.N G L c 10. §'1; 1.7 Flood Zone Information: i.8 Sewage Disposal System: Zone. _ Outside F(R) Zone'! >lunra al ❑ On ,ire Ju>t,sal '�v,rcin ❑ Public ❑ Pn rate❑ Check if yes❑ P I —� g SECTION 2: PROPERTY OWNERSHIP' (� /�/ Ow nt , c- �_.�rd: /' O JQ..L e,-1-1i --- Nwne (Print) Address for Service Telephone Sienature— SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) l New Ew iruction ❑ Existing Building ❑ Owner-Occupied ❑ Rep:ursisi :\Iter,unm(s) ❑ :\JJnn1n ❑__I DenwlititIn ❑ Accessory Bldg. ❑ Number of Units— Other ❑ Speedylit B ref Desci ipuun of Proposed Work: Cx.it I n �— SECTION: a: ESTIMATED CONSTRUCTION COSTS E,ttmatcd Cost,: 1 Offi Item (I.ahor and \LUenals) c•tal Use Only I Building 5 0©6 I. Building Permit fee: 5_ InJiwte boss Ire i, Jrtri nunrJ. ❑ Standard City/Town Application Fee n Electrical S I ❑ rutal Project Cost' (item G) x multiplier t. I'lumbrng '� '. Other Fees: 'S 1 Mechanical tH\':\C) 5 List: --- - - --- 5 %lechancal Ifire I \upprovnr � rni,rl :\II �res: S — ('heck No ___('heck Aimiunt h total Project Cost 1 � 000 Cl P.uJ ut Bull ❑ tiutst.inJin_ B.i l.r nsr Uuc r SECTION 5: CONSTRUCTION SFR� WES 5.I Licensed t'oiislructioitSiiper%is4)rlt'Si.) I ,,-fz-e NsumNr N.,111col t sl, 1 1 ( S I k IV-,cc h,1, Cr _AJ KRC,t1,,1Cj \t-, an R( if Jclto"l 11"1101, I cicphmic H,,d, 1(,1 %\ :1,1," oJ 1p, S,kj I ,,I if !1,11 -1 H C,I I I I I lu.i:., II 5.2 Registered Iforne Improiernent Contractor ill[U) HK ( ,Iiiljlaii, \,111cof HIC SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affida%if must bec,,mpletedand 'Uhinined with 1hJS .1ppIJLa1-'111 J:,oJLJrC In IMIuJC. (hisatfida%ir will result in the denial M the issuance of the building permit. Signed Affidavit Attached? Yes ....... No — SECTION 7a: OWNER AUTHORIZATION TO HE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner th•.• re,,hi,:,i po,reit� hereby 1- al: matters lithi.l.ze iir 41. 111) to •.%orK authorized by th;, building permilapplication. Owner ,3wiliture of Ow Date S SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION I 1. as Owner or .%uthoi /ed \�--enr hereby declare at", that the statements and6o information on the toregojmc appficationaie true and accutdie, to the best-of my knok%!cdge and behalf. Print Name S11411atUre of Owner or Awhoii/ed .%getit Date S;.rrcd under the Cam,and penalties of l2er uryl NOTES: 1. An Owner who obtains j budding permit (odo fits/her own who hires a ) (no( registered in the Home Pm.,ra tin o. will iv)l hale access i.) the Lit hit'all"n program or guaranty fund underM.G.l. c. 142A Other important infoinridlionon the HI(' Pri,gimn Lod C1.1"INJILIC111M Supervisor Licensing WSI.) can be found in 780 CMR Regulations I 10,140and I M R5, When uhaamial w,)rk is planned, pnoide the nt�)rmjtwn helow r,itai floors area i Sq, 1:1.P including rig girage, finished hd1C1oCf1U.it111 S, decks ,r p,a,11, Go, 1o,m,area ;Sq Fr Hohitahle P,u,ni .,,unr Number "t fireplaces-- Number M hedro,,in, N,jinher it haihi(,„nis NLW&�r q hal� h.oh, I\jv „f heMMIZ 1c11CM Number , t lc,k,, p, I he, I pe (ern J;,en 1",6al Pr,,)ei,t Square man he uhsofuted t,,i F,(,d PlojeA " CITY OF SALEM j PUBLIC PROPRERTY DEPARTMENT IiI v-S 't; \e. 97x-V_ Construction Debris Disposal .-affidavit (rcgtiircd lbr all demolition and renovation work) C i In accordance \%idi the sixth edition of the State Building Code, 780 CMR section 1 11.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit it is issued with the condition that the debris resulting front (his work shall he disposed of in a properly licensed waste disposal I•acility as defined by MGL c l 11, S 150A. The dehris will be transported by: G� 44 (namc of hauler) The debris will be disposed of in c- LA-t (name of facility) - luddre�. u(1�cilav) .. agnaturc ,>f pennrt ,gy>hcant . g ,late CITY OF SALEM 1, PUBLIC PROPRERTY =r' DEPARTMENT .1 rota K:IN":)Nlilt u 1 12C WASHIN61J.N 5IxLi r SA h:.\(,MA».1CIn it'I IN 01973 1T.1.:978-.'i5-9595 • Ilsx. 978J41C.A46 Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1 )li�ant Infortnrtion / 1 Please Print Lecibly 81n( ``�AC6( k00SsztLa4 f d`j� Address: City,Sratci7.iP:�AA)JQ02S M01 Qf'?� Phone Arc van an employer:' Check the appropriate box: 'Type of project (required): 1.❑1 am a employer with / 4. ❑ I am a acncral contractor and 1 6. ❑ New construction employees(full and/or put-61116 have hired the sub-contractors 7. ❑ Remodeling 2.❑ 1 am it sole proprietor or partner- listed on the anached sheet. : - ship and have no employees These sub-contractors have g. ❑ Demolition workers' comp. Insurance. q, ❑ Building addition working tier me in any capacity. iNo workers'comp. insurance 5. ❑ We are it corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their right of exemption per MGL I I.[] Plumbing repairs or additions 3.❑ I am a homeowner doing all work C. 152, y 1(4),and we have no l2.❑ Rouf re myself. LKo workers' comp. p�afirs D insurance required.] ' comp. insu insurance workers' 13.�theref �✓Id1� t°A!/t comp. insurance required.] •nn. ,rilicant that checks box 91 must also till out the secGal,Ixlow showina their wvrkets'cumgsensation put icy iutianettion. 'I Iom.uwmen who Iubmo this atYdavit indicating they am Joins all wotk and then hire outside cwurnetom must nuhingo a new atr:davit indirdmg such. { mtrxmn Ihm check this box musrauachwl an adlilional sit set+hawing rite name of+ho sub-contractors and their workers'comp m.policy inforadnn. 1 urn rah employer that is providing workers'compensation insurance for n+y employees. Below is rite policy and job site iofornhalirta AV Ilnuruucc Company V:une: l\ - r-/ .._ .....- --. - ------- Pulicv b or Self-inks. LiC. > : ------ � - _,. ..__ Expiration Date: U 8 _ i32oi4�C Job Site .-\dJnss:�� S � ___ City;Statei"Lip: S'q o- .\ttach It copy of the workers' compensation policy declaration.page (showing; rite policy number and expiration date). I;ailurc to secure coverage as required under Section 25 A of>IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00;t day against the violator. He advised that a copy of this siutement may.be forwarded to the Office of Invvstl,auons uh thJJe,,DIA i'or ioiurar cc covcraye lerilicalion. /r!a her V,J!t+t •r the pahu'and petal ' erjury that the information provided above isrntt and correct. I'h�one r• official use wdy. Do not write in this area, to be completed by city or town official. City at I"own• _-_. _. Permit/License 4_ . .. Issuing;.%ulhorilp (circle one): I. Hoard of Ilvallh 2. 1111ildiu:; Department 3. CityTown Clerk 4. Electrical luipector 5. Plumbing; Inspector 6.Other Contact Person: _ . .__ Phone tt: � Y y Information and Instructions Aiassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pu Bututt to this statute, an emplt avee is defined is "...every person in the service of another under any contract of hire, etpress or impliod. oral or written." An employer is defined as"an individual, partnership,association, corporation or tither legal entity, or any two or more or the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased empluyer,or the receiver or trustee ul an Individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the-rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall inter into any contract for the performance of puhlic 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 that upply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Offleials - Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant Iltat must submit multiple permitlliceise applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. flu 0ifice it Investigations would like to thank you in advance fur your cooperation and should you have ;my questions, Please du not hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents OPHce of Investigations 600 Washington Street Boston, MA 621 l 1 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Page 1 of 1 Thomas McGrath From: Jane Guy Sent: Thursday, August 14, 2008 3:37 PM To: Thomas McGrath Subject: RE: 35 Broad Street They have approval from HisCom for chimney repair and chimney cap. They are going before the commission on 8/20 for a skylight. Jane A. Guy Assistant Community Development Director City of Salem Department of Planning & Community Development 120 Washington St., 3rd Floor Salem, MA 01970 978-745-9595, Ext. 5685 (F) 978-740-0404 1guy_0salem.com www.salem.com From: Thomas McGrath Sent: Thursday, August 14, 2008 3:35 PM To: Jane Guy Subject: 35 Broad Street Jane We have a building permit application for above address......for masonry repair, pointing etc........have you reviewed the scope? Thanks Thomas McGrath Assistant Building Inspector City of Salem 978-745-9595 x5644 8/14/2008 1 Na APPLICATION FOR PERT«TO LOCATION 35 91-a"0 S� PERMIT GRANTED 19 APf INSPECTOR OF BUILDINGS 4%N SIAtl6t1111E AID APPROVw f3Y TW MLDZ IOB PWOR TD A PMW AKM GRAWkD CITY OF_SALEM No. Oft T /� Wad �, zNwp owns ft MIM4ic DY41w Yes No loeatios of a PIaNIY Locom in Ir Cwmnm@ n AMO YM No_ Permit to: ION BUILOM PEW APPUCAT FOR; (Ck b whiohawr apply) Roof. Rowel, Install Sldtrp, CWWW Dade. Shad, Pool, Rapai�/Raplaoa. Other: PLEASE FILL OUR L MLY a COMPLETELY TO AVOID DELAYS N PROCEg@M TO THE INSPECTOR OF SUILDINOS: heieby applies for a permit to bLdld amr&-q to the bkwirq Or+WsName �/PllCn Addmu a Phone 7s! zrr a a 41 _s;4 ( t Architect's Name Addmu a Phone f Mechanics Nanois/ Address a Phoro /,/ /-TrAws�re /5i4N y,G R s .4 Whd a 1»prpon it bliYtlrlp? kilt"or brdop4 491- cod 1 a dweaiq,for how MWW MiM9 WO baking-n M 10 INN ArDnbs9 gn v EMrlwa ow �?, o_°° qA►uoNw r stw uoNrN r �i y �l l 2 �. � ioz tiro 0vidum of 8W=UNDWt1W PENALTY OF PEawRY DES,/Ci10N OF WORK TO BE /Y ivin DONE st � ✓y / f 0-0 0rn9'1 -/ S MAIL PERMIT To.