2 CEDAR STREET CT - BUILDING INSPECTION PUBLIC PROPERTY
lil
DEPARTMETNT
KI%MFJUEY EMSCULL
MAYOR 120 WAsHtNGTON s RFEr
"'-EK mAtSACJft;5tzl5 O1970
TEL-978-745-9S9S 0 FAIL 978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: ralar T cou r Building:
- --
er�arcw. F. eon Po lci 6
property is located in a; Conservation Area YIN 1, Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: i GGJflk
Address:
Telephone: 1 0'6
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: Lz)
�\1� (
KWCAD_1 v4�CI,2P%S�� an InoRs
'�UtC,� .
Mail Permit to: Mal r 1G11)
What is the current use of the Building? °EytC�k
Material of Building? n If dwelling,how many units?
Will the Building Conform to Law? � G Asbestos? N()
Architects Name t�f1fJ6
Address and Phone
Mechanic's Name RZ NAl- G N t3KJ
Address and Phones �� o�r�U (4 #%
Construction Supervisors License# « Mol HIC Registration#
Estimated Cost
of
Project$ — Permit Fee Calculation
Permit Fee$�SY+ 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 build to the above stated
specifications. Signed under penalty of perjury
Date ot alol
I
0
\ N
y
� Nnt� tA
_----
r.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
txn.eaaxa,r uaacoxi 'I
MAYM uo WAslmW.rori Snigr a SAIM4 MAUAQMWM 01970
TsL•97a•743-9595 a FAX:973,740.""
Workers' Compensation Insurance APQdavit: Bnilden/ContracteraMectric[an&Tlumbers
Applicant Information I Please Print eaibly
Name(Btneinesa/Organiatioollndividual): CR (HRL U 06
Address:_- 14G Adva Uo
City/state/Zip: Q621) Phone ok
An you a■employer?Check the appropriate beesF7-
bvrequired):
1.0 I am a employer with 4. 0 I am a SmIt
ontractor and 1
esepioyeea(firll and/or part.time).• have hireub-co nrectu s uction
( amstrkpwpdew or partner. listed on tched shoot•t g
sp and have no employees These metesctarg haw working for ins in any capacity. workers' Wmnanee,[No workers'comp,insurance 5. 0We are a adm and id dition
reed.) offices hscisea tick 10.0 Electrical tepaits or additions
3.0 1 am a homeowner doing all work right of en per MOL 11.0Phimbing repairs or additions
myself.[No worers'comp. e. 152.f 1d we have no 12.0 Roofrcpaira
msc usce required.)t employc� workers' 13.0 Other
comp inw required.)
Any applicant the caaab boa at mwt dao all eta the action below stowing dak wo kmu -
Homaowams who submit tttb waldava g day am doled as wok and din tine amide I��a owr alidak
tCaarnetaa tit chink dtb bet mane suached lie additioml sham showing die owns orris sob4mommm and dtdr watvtaI camppWicy Wan"adOIL
In orara OMPIRYp that Is provN&S workers'compeeaadon Wamocefor my employee. Below tr the poLtry and fob ruins -
I
Insurance Company Name: �DbCD A InSU
Policy N or Self-ins.Lie.
nnAk pp CS Aq '41, Expiration Date: a-4-
Job SiteAddress: 2 lxtYOt SE. Gpor , CCity/SWe/7ip:GhJEh1 MA O)C'R�
Attach a copy of the workers'compenatlon policy declandoa page(showing the poiley number and e:
Failure to secure covers as expiration date}
ie required under Section 25A well
MGL a 152 can lead m the imposition oPcriminal penalties of a
fine up to$1,300.00 and/or one-yea imprisonment,as well as civil penalties in the Pam of a STOP WORK ORDER and a fine of up to$250.00 a day against the vioblmr. Be advised that A copy of this statement may be forwarded to the Otllce of
Investigations of the DIA for insurance coverage verification.
!do hereby erBfy ender Ae pahu and penalties ofper/ary the the injormadon provided above Is tray and cor-m-ca -
Sismarure, . u Dare nl I� I p}
P_hone.A (� 19 RII1
Of)leld use only, Do not write As J*19 area/o be completed bl'cAy or lows oA*UL
City or Town: Permit/License N
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.CityfTown Clerk 6.Other 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone 0:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to rken'compensation for their employees.
pursuant to this statute.an earpfoyee is defined as"...every person
le the servicean
a" any conaadoflfstsr,
express or lmpliA es+l of wriu °'"
aaaoeiatiOr4 w or other legal entity.or any two or more
is defused as"an individual.parmashtP+ of a deceased employat.or the
o f serpfoya m a joint entaprise.and including die legal representatives
of the foregoing engaged association at other legal entity.employing employees. However the
trusses of an"vidual.receiver 00 owner of a dwelling horse having Out tom�n thm end and who midst therein.worit an each dwelling house
ac the Occupant of do
dwelling bouae of mother who employs Persons m do not because of ropl yin be deemed to be an emPIOYW-"
or on the grounds
or building appurtenant thereto shall net because of such emtployment
state er local"causing agency sloes"withhold the sou w
MGL s,Ofs 152,ssi$tor pe salsoeft states that"wary i•tho commonwealth for any
too a business or to eos�net boildln¢ aysn¢regdred."
reauwal of a o haso or Produced acceptable evidence of eomptlaua with tM imannna
applicant who has not produced
Additiaoally.MGL ebap+s 132,$23C(7)states"Neitherthe commonwealth nor any of its Political subdivisions
sball
of public work until acceptable evidence of compliance with the inwranao
enter into any contract for the performance to the contracting atitbeaty. >__.,
requirements of this chapter have bean presented
APPtleub
ompensadon affidavit complotcly.by checlting the boxes that apply toytr a situation
Please till out the workers'a and,if
necessary.SuPPly+ O° Or(s)aamK+�addrae(e it and above number(s)along with with employees other than the
insurance Limited Liability Companies(I l or Limited Liability Partnership+(LLP)
members or carry
Partners,are not required to workers'aOmpassd=instuance• If an LLC of LLP does have
employee.a policy is required. Be aid that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insuranee coverage. Abe be sun to 91V and date the affidashould
vlL The affidavit
be retuDepartracut of
rned to the city or town that the application for the permit or license is being requested,to obtain a workers'
Industrial en policy,Please ca Industrial Asxidenta Shouldy ll you have any gnesdow regarding dte law or if you arc required
the Deparuseet�numbs listed below elf. Self-mauled companies should enter their
com
self-insurance licon numbs on the
City or TOM Omdsd
complete and printed legibly. The Department has Provided a space h the bottom
Please be ore that the affidavit is comp
of the affidavit for you to fill out in the went the Office of Investigations has to contact you regarding the applicant
Please be surd to fill in the pmmitftense numbs which will be used as a reference numbs. In addition,an applicant
lications in any given year.need only submit ones affidavit indicating current
that must submit multiple perm vhcmw apP the applicant should write"a"locations in_--(�Y or
policy information(if necessary)and ands"Jab Site Address- or marked by the city or town may be provided to the
town)."A copy of the affidavit that has been officially stamped or license&-A new ai-"&vit must be tilled out each
applicant as Proof that a valid affidavit is on file for Wine Permit not related to any business or commercial ventureyea.Where a home owner or citizen is obtaining a license or Permit
to burn lava etc. said is NOT requited to complete this affidavit
(i.e. a dog license or permit ) P+r+on
The Office cense Or li mat would like to thank you in advance for your cooperation and should you have any questions.
of
please do not hesitate to give us a call.
The Departrnemt's address,telephow and fax number:
The Commonwealth Of MiSStChUSetLl
Dep3[lmeW of 1nd1L9t17a1 Atxidenb .
Omer of levesdPlIGoa
600 Washington swat
Bt>stm MA 02111
TeL M 617-727-4900 W 406 tx "77-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 wwi=wgov/dies
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0002 .CEDAR STREET COURT 566-07
Glsa: ;sa66� COMMONWEALTH OF MASSACHUSETTS
Map: i34
— - - - - CITY OF SALEM
Block.
Lot: 10104
Category 'RCPAdR,/REPLACE
Pdf171it -_=566 0/..._ ---_ BUILDING PERMIT
Project# ]S 201)i 000836
Eat. Coil SL00000
Fee Charged: 1$25.00
Balance Due: i$ 00 �' PERMISSION IS HEREBY GRANTED TO:
Const. Class: _;Contractor: License: E.rpires
Use Group: ----_ . .. -._.___ICATHALGLYNN CONSTRUCTIO SUPERVISOR - CSOS'7a'_
.,
Lot Sizeisq. It.): 14623 -_-- -----�- - ------ !Owner: E!vi?G;trCi:!
!R^_
Units Gained:---_-_ _ --- --- - 'A licarit: CATHALGLYNN
U 1 p
Units Lost: AT: 0002 CEDAR S'I'RLE'C COURT
Dig Sate N:
- -- - - - - -
ISSUED ON: 03-J,,., 10n AMENDED ON: EXPIRES ON: 03-)ul-200;
TO PERFORM ?'FIE FOLLOWING WORK:
DED10 KITCHEN C.31-'IP'ETS& DIOLDING
POST THIS CARD SO IT IS VISIHLE FROM THE STREET
Electric Gas Plumbic", Building {
t nderpruund: thtdergr mud: t:ndergrunud: Earavaliuu:
Service: Meter: Fuo links:
Rough: Rough: Rougi:: Foundation:
Final: Final: Find: Rough Franz:
,,. ._ Fireplace/Chimov%:
DTAV. Fire Health
Insulation:
Meter: Oil:
Final:
lluuse 8 Smite: .. _ -
Treasun:
Rater: Alarm:
14
'Seacr: iprinkle;s:
THIS PERMIT h1A5' B) RF.VC KEfI BY THE Cl'fY OF SALEM UPON VI A' ) ( F ITS
RULES AND REGUI ATIONS.
Signatwe:
Fee T)Pr. e. 1_ Receipt No: Dine Paid: Check No: auwunl:
131 ILDIMi - REC-2007-001031 03-Jan-0 Cush S-'?I11:
IMPORTANT: .�r iuspeclic.tis .REQUIF
upon compk :ion of work, please call
74!,W 95 Ext. 385
k,co I ms&?Ikl7 Ues Luuriw IVL-mcipl Sul coons,Inc.
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