4 CEDARHILL RD - BUILDING INSPECTION What is the current use of the Building? /n -�-
Material of Building? /.rr a v t If dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name G!a A /✓�£s` z 3 5
Address and Phonenn
Construction Supuumisors License f{ a crc-&-6 HIC Registration#
Estimated Cost of Project S /� Permit Fee Calculation
Permit Fee i� Estimated Cost X$7/$1000 Residential
EadmatedCostXS11/51006Cormrmerciai—
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 build e a e stated
specifications. Signed under penalty of perjury
Date l �
3 �
a w
x or
PUBLIC PROPERTY
DEPARTMENT
.uro�••�,onsa�u.
SMAK%(.\SSAa1l5611501970
To-, S.7454S"0 FAr 97L740.98M
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUII.DING
1.0 SITE INFORMATION
Location Narnw. Building:
_------ - Property Address:— - - - - - --_.-- --
C e.c. .
129
Property is located in a;Conservation Area YM l3 Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: r(s- T� /J/J 7—
Address:
Telephone: -
3.0 COMPLETE THIS SECTION FOR WORK IN EXULTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
9cief Description of Proposed Work:
p
-- -- Mail Permit to: ��
CrrY of sALEM
PUBLIC PROPRERTY
DEPARTMENT
>,twtaear ts..ar,..
ut.t,e
LJC raoa Val1olrltUff a Salem,liras we*„x 0IW3
ThU~4&""a F.sx:gW40.Wea
Workers' Compensation Iasursaet Affidavit: 8rildera/Costracton/BlseWdanwl%mbm
A
Is
PH 11
Varnorw.iK.,ro,yr;:uiortny�wmn: ^L�e.�,�J
AJd
City/StaaivZip:
Are yell as erpMyort CYaeY eM aPPr'oPrlNe�Mst
1.131
d a employe w(tY 4. Syr ore r ll eootraaor and l n�°f ProjKt(rNdrb}
luyeat(roll amUor puro-time).* have hired the A&Cututsctors d' Q New construction
a sow ptroprlesor or psnnar6 lister on the aftebad shoat, t 7. Q Remodeling
and bave no amploywn Tban hat,,. g. Q Demolition
kt
mo in my capacity. svorkaMI'eontp.indunflon,'camp. insurance S. ❑ We am a Corporation end its 9' Q I�tildinS additias
otTkoms have exorcised their !0•Q 0octrical repairs or addwona
owner Joins all work rism ofexampitimt par MOL I I.Q Plumbing repairs or additiomworlten'wmp. C. 152.#!(ex and we have no 12.Q ltuof:rpaier
°AeO r« ii td•1 t emPby�s(>•o workers•
comp mwusamrequimdj 1)•oothsg
'A,•!+PP�W tree der ' Bag el oar arse all as As ucaee Babr'aaa'iaa rtte'r ramp'aropaaaart r y,�;,s,ioirwria►
'II.wAariarrra Who waait tV alederY aMloi6s oral'ate dotes ae emd sea ons alas sotNs easeroeton sear.eAnL a oar
r'werxatra tha caaek rain Bet aura aeadnd as addNfmal allot Jowiy lot nave of aY a�mikoina uadl
ass rang wAoa•cow Popsy M6,xueoa
/oar an einpbjw that b provid►ng WW*Ws'roarpentaaon hunroneir jar my e/np/oyeea Bdow/a thep'rNa2- w/°�.
.. .. _..._._ ....._.-
Imurance Company Van . e/
Policy a or gulf-ins. Lie.0 Expiration Dater��(,' 6
Job Site Address: City'SlatuZip:
t rtaeY r copy of lM weaken'compensation policy Jaelarallon page(showing the polity number and c:piratlue }data
Failure to secure raverage as required under Saclion 25A of.IOL c. 132 can lead to time imposition of criminal penal of s
ties
ginc up us 51.300.00 and/or one-year imprisonment,as well as civil pensiliea is lha form of a STOP WORK ORDER and a row
of uti to$250.00 a Jay ug:riam the viul210r. lie advised that a wpy urthis slatcmem may be turwardcd to the Office of
hee;ahgawrns eyrie DIA for in.urarcc:ov.radt: s,;'crii ation.
/Ja herby ran' under the aa1l ptnall&s a�perfan7lhar/he i/r OIA•W/0I
/ prodded above is one and correct
Ci•:r,hie•. _
U/Jltya/are an/2t /Jo ea/wr/!i/w/h4 ana,m M rowpkfdAp e/!p or taient a,0'4•/a[
City or 'rower Permit/Lkcass g __ _
Issuing Aulhurily(circle Gila):
I. Board
4her of IlraltY 2. Building Drparcurcn
G.Other t I. City/fawn Clerk i. Electrical Inspector S. Plumbing Inspector
Gntlaet Person:�_ _ Phone p:
Information and Instructions
ya"achusetts General Laws chapter 152 requites all enplOyete to provide workers' canpensation for their employees.
Putsduaatt to this susttlR r ewl/p'7'"
is 406 as'..Avay person is the samice of another under any cmusa of hies.
«puss or W"h% .dNa1 at written
is dttliad r n iadhndsal psteaereYig►rsoetatte&cs�ss at other kgal enddaY•or,any two or arenas
.AA ea foregoing engpged is s sesadPftee.and isehslbtg ft kgat reyreeeotasves of a deceased employer. the
tyrceivdsr dY tttleaae of on iydtvndtsd.P�'�astocado s or cabs:legal cadge.ampbYudaemployees-
ate havisg act mats than tYsse apantrtasols and why eaidsa thteeiet.ar the oeettpsd of the
�i ng o[kouss h other who employs Persons eo do msinsessne+.coosa+wseat or r o be a
awaiting house
dwelling
r sdt ar bttildhag sppta'tassst there:shs9 net bsaattes of era►stt�lsYasaat
or on he fTodd an CWP1QYM*
Mg__
AtGL chapter 132.423U6)Wan Steed too a lrfn�e a ��O�mrrsnwea K
Coverage r@40*W
renewer Of•amtw er pstrsett r operate evidence of comptlsaee with the Insurance shall
applicant wbs bea ant Pgacesdable tar,say of in political mbdiridi
e+tGL chapter 152.6�y)Mer')lsidder the onntannv- is e
Addirioealty. ties the prfycmesce of Pd+ae work until acceptable evidence of codsPliaaee with the insurance
tsar imo my comma chapter bids to the contracting audlod11Y••
rcquirsmens of this d9aepese have presented
AOtslleants te situation tad.if
pteass Jill not the workers'aompewatiest ttM&vit Completely.by checking the baza diet apply Your
e)nme(s).address(es)and phone comber(s)along with their cmritica�a)Of the
necessry,supply nab-eess's C tl ies(LLC)or Limited LWnikY Pormu&ips(LLP)with ao employ ths
4mumnes• LimilddLisbilit
m carry w �. imunnee. if an LLC or LLP does have
employes r ppolic u� he advised t�the affidavit m y be submitted to the affl"Depar stanc of [sine ial
it
employees,a policy of insurance emasp Also he sore te sign tad date the atlldavlR The at Jidavit should
Accidents for cmAmtaties that applieaclan for the permit or license is being requested. so the Deparlmast of
be returned to the city or sawn the kw or if you are required to obtain a worker'
laduserial Accidenu. Should you have any questions regacdina below. Self-isauted aompan!"should sniff their
call the Deprtmeat as the number listed
compttnsstion policy.pkaso lies.
self-inwrance linter number on the
City erTo"OQletsk
fete and printed legibly: The Departments has Provided a spas at dte.bonmt -,.
please be sure that the affidavit is comp the applidanL
vesti
of the afRdsvit far you to Felt �l tea event u berwhich
towill be used as aSations reference contact you
rdditim,an applicant
Please be sure to till in the pu number
is any given year,need only submit one affidavit indicating cutreat
that must submit multiple permit/license applications ,rear should write"oil locations in�_(cicy or
policy inPortnuion li!necessary)and sunder"lib Site Adtampe ohs marked ry
• the l of town may be provided to the
townl.'A copy of the affidavit that has been officially stamped dot a licensee. A new affidavit most be filled out each
applicant as proof dot a valid affidavit ism file for nature perm me tar related to any business or commercial ventureyes. Where a home owner or citizen is obtaining a license or pen
d i.e.a dos license or permit to bum leaves sot.)said parson is NOT required to complete this afHdsviL
IN; Oftix of lnvestigatiuns would like to thank yAw in advance for your Cooperation and should you have any questions.
i,lcabe do not hesitate to give us a call.
The Department's address.mlephor and fsa number.
The Comnlonvrealth of Massachusetts
Deputmeat of Industrial Accidents
OI! w of Iavestipdooa
600 Washillow Sf d
Baatwk MA 02111
Tel. M 617-727-4900 W 406 cc 1-977-MASSAFE
Fax 0 617-727-7749
2cviscd i-26-05 www.ana.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
n.w�al ar• �a`Il
aL�u• lffi1.�rw:.Y+l7EtT�i�lc1M`htAVltf:N*A1b :9.
TS;rINwm fate IW4604
Consimcdon Debris Dbpossti Affidavit
(requital tor an dentorwon and smovation worst)
1,arcadamc with the S46 edidon o[dhs sets Building CodR 790 CNIR soctiosh 111.S
Ikbds.and dw provisions of M. GL c 40r 9 Sit
quiidiss Permit 0 - _ is issahed with the condition that the debris reaWns frees
this wodt shall be disposed of in a property licensed waste disposal fbcility as defined by MGL o
11t.=110A.
The debris
/w,ill be transported by:
_ Ric,(4AP�p ,QAI AA/J/SO/1/
home of heater)
rho -brie will be disposed or in :
S4G1 -
1 saw of facility)
.+J�:rsan of t'xaw)
..W
} - 138 4"
49" �r 3711 �- 52 4"-
dN,
I �O5ONl / W2430 W2730 -DW� 30o24
24
F 24.DISHfv
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FINAL PLAN
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All dimensions size designations given ere 11tis is ao original tlesign and must not be Designed:(t/25/2007
subject to verification on job site and releseed or copied tales applicable&e has Printed:8/25/2007
adjustment to fit job conditions. been paid or job order placed.
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................... ...................
FINAL PLAN
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All dimensions sire designedons given ore This is an original doeign and must not be Designed:9/14/ 007
subject to verification on job abe and released or copied unless applicable ire has Primed:9/14/2007
adjustmem m flit job candir[ana. been paid arjob order placed.
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30" 9"�—
132y1 42"a.. i�� H}" "
101'e" 475" • 70$"
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All dimensions.ma,deaignations given ere This is an origlnai design and=r not be Designed.9/l4/2007
a abjee[to verification on jab cite antl .1..ed or wpietl anima�plieable the hos Printed:9/14/2007
u4jusnnent to St job conditions. been paid orjeb order placed.
HI 1 Drawing fl: 1
91406466.Id[
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24" 24" 39"' 27" 24"
(D m
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3
25;"-- -- 24" — 27" 21" 36"
All dimensions 9iza designations given are This ie an otigbtal design and mus[Tot ba Designed'9/14/290'/
¢object to verification on job Biro and released or copied todess eppllcebie Re has Printed:9/34@000
adjustment to fit job eonditiooa. bean paid at job order pi aced.
91406466.ki[ _ Ell Drawing H: 1
170.e--"
24.. 9", 30" 1 107a"
• M M.
t-
DW3 424
^h
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SLS363
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137:" �
48" --;�-- 334" 524" 37'
All dunensions-size designations given areM[b...Paidorjobordcrplaxad.
ism original design and must not be Designed:9/14/2007
subject to verification on jab site andased or copied unless applicable Fee hoe Printed:9/14J2007
adjustment to fit job conditions.
91406466.kit JFJ I Drawing 4: 1
o a
o '
❑❑ o
C
NeG::This 4r¢Wing is oa arLsdc D¢aiB�ra4:9/34/200�
inwMramtion ofthe 9e ral appearance¢f Prl¢ted:9/14/2007
die design.it is nor meant ro be an—am
rendition.
91406466.kit brewing N: 7
0
n
I N
Note:This drawing is en orratic Designed:9/14/2007
inleryra,tron of the genend app-wee a Of Printed:9/14/2007
the a`s f.1[iY nna—..m be on runt,
rendition.
C
91406466.1d, Drawing 0: 1
i
i
Now:1Lis drawing is an srtistic Designed:9/14/2n0�
imerpmwtioa eftho general appearance of printed:9/14/2007
the design.It is twt meant to be an exact
revdidoa.
I y
91406466.kit Drawing N: 1