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10 FLINT - BUILDING INSPECTION No.l City of Salem Ward -� C d9 COQ I APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete all items in sections:4 11, 114 IV, and IX. L AT(LOCATION) LQ �/!h IC// - ' ZM LOCATION NO1 $ OF BETWEEN AND 1AO�5T"�" cAossLOT n BUILDING SUBDMSION LOT_BLOCK SIZE IL TYPE AND COST OF BUILDING -All applicants complete Parts A -D A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOLITION"USE MOST RECENT USE 1 ❑ New budding Residential NOtrMtlentlY 2 ❑ Addition In msoi nhel.saw numbers new 12 ❑ OM mmdi, 1 a (j AMMWNrrL racreahonml housing units added,d any.n owl D. 13) 13® Two or mole Family-Enter mrs'" wk 19 ❑ Chnother re ids 3 (3Aberation(See 2 above) d units—3 20 ❑ IndubW 21 ❑ Pig garage 9 Repro repmcenwra 1a ❑ Tnrmon noddbar a model.or dpnmlwly- 22 ❑ Sanwa staban raper garage 5 Wraew (amu fstrnumberd unila_______� ❑ ax3 lOfanrry nxdrbaL enMnurrwer 23 ❑ FloepihlL institutional of units in budding in Part D. 13) 15 ❑ Garage 24 ❑ O(8cs.bank pnolsaswnW 6 ❑ Movmg(ndocat inl 16 ❑ Carport - 25 ❑ Public ubft 7 ❑ Foundation ordy 25 ❑ Sdwd,ibrary.atter eduogontl 17 ❑ Other-Speedy 27 ❑ Storw nsmods is S.OWNERSHIP 28 ❑ Table,wwens BfiaPirelli.Ind.dual,poradiation.nonprdn 29 ❑ other-Speedy �natiMion,MGI 9.❑ Pudic lFedenl.Stats.or dial governnan d C.COST {-GU (Omd Wfli) Nonresidential.Describe in demi propaf.d use of buildings,e.g.Mod processm pont J many.Map,laundry budding at hospdid eMronmry school.secondary sande).0:419W V panecoo adrod.ow"garage for deoani ld, atop.m. of euddng,dfiea binding 10. Costal S at industrial dam,g use at ex is"budding is bang otrange4.coed txolwsed us. To be Maraaea but not rrcreded in tits slow cost r iO G a. Elecsrtal___ t OW L bK01101" 0. O"W Ietsvww.MG ' 11. TOTAL COST OF IMPROVEMENT 3 u IIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L•demoldbn, complete only Parts J 8 M,all others skip to IV E. PRINCIPAL TYPE OF FRAME F. PRNCPAL TYPE OF NEATING FUEL G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECNANWAL 30 ❑ Mowry tvq/Ir.reg) 35 ❑ Gas 40 ® Fund«txrvam canpany Will gds be orrM. 31S Wood his 36'0 Od 41 ❑ Phwr Is.pte tad.MGI toi0eoninq? 32 ❑ StruehaW ete d 37 ❑ Elsctrftily 44 ❑ Yes 45 a No 33 ❑ Reinpesa comer 38 ❑ Coal K TYPE OF WATER SUPPLY WR time by an Memedn 34 ❑ Ogrr-Speedy 39 ❑ Other-Speedy 42 (�l PubYe air company ae ❑ Yes 47 vP No 43 ❑ Pdvar)wad,coWni J.DIMENSIONS NumM' MEMOLITION OF STRUCTURES: is a . Or 5101185 ._.._._................................_ M.........._. , ss. Torn aware ren of mor area H proval from a.:mors oases an asteria Historical Commission ope fi-recerved ,,mer ons ...........-..._......_......_............................._._.. for an tructure over fifty(50)years? _ No_ 50. Total wnd ams.W.a......___......................._..__ Dig Safe Nu K.NUMBER OF OFF-STREET PARKING SPACES Pest Control: HAVE THE F OWING ES BEEN DISCONNECTED? 52. dutdoas.... .._...__.._.._..__.._—_...__ Yes No L RESIDENTIAL BUILDINGS ONLY > 53. ErKlmed_..... Fuer—_-� Steer. 50. N~of wwoon s BEFORENTATION FOR THE PERMIT CAN BE ISSUED.MUST BE A HED ' IV. COMPLETE THE FOLLOWING: Historic District? Yes_ No_ (If yes,please enclose documentation from Hist.Com) Conservation Area? Yes_ No_ (If yes, please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No_ Is property located in the S.R.A. district? Yes_ No_ Comply with Zoning? YesAL No_ (If no,enclose Board of Appeal decision) Is lot grandfathered? Yes_ No_ (If yes,submit documentationld no,submit Board of Appeal decision) If new construction,has the proper Routing Slip been enclosed?NO/— No_ Is Architectural Access Board approval required? Yes_ NOL (If yes,submit documentation) Massachusetts State Contractor License# 0 3 Salem License# Home Improvement Contractor# k` 11 1 Homeowners Exempt form(if applicable) Yes_ No_ CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT CONSTRUCTION IS TO BE COMPLETED BY: If an extension is necessary,please submit in writing to the Inspector of Buildings. V. IDENTIFICATION • To be completed by all applicants Name Mmwq address-Number,street cry,and me LP Code TeL NA I. AUrTC'CChr <n �� 'UVtrc� r(L+� 2rJ Wf. OwMr or C? Lamee 2. r �►� J kl. au-Q4W Gtr(v-f 91,14 0f;q Buldafe l cents NQ 3. A cromm or FJtgneer I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized anent ana we agree to conform to all aoolicable laws of this jurisdiction. Signature of appf t Add — / AD lica on date DO NOT WRITE BELOW THIS LINE VI. VALIDATION Building FOR DEPARTMENT USE ONLY Permit number Building —C' Use Group Permit issued u� 19_ Fire GmdaV Building Permit Fee $ Live Loadirg Cerfificate of Occupancy $ Approved bOccupancy Load y. Drain Tile $ /�ia'h.� v5�� Plan Review Fee $ z G •��Ll t� TITLE NOTES AND Data•(For department use) 'e RT' l7 V4 , M1 ' -/z �'CA ch ��115 fh bro PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by. Completed by. VI ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES 1 I SITE OR PLOT PLAN •For Applicant Use 1 3 O N j d 1 i CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1'. SALEM, MA O 1970 TEL. (978)745-9595 ExT. 380 FAx (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition — — - - of Building-Permit-# ,-all debris resulting-from-the-construction-activity----- govered by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S150A. The debris will be disposed of at: Location of Facility Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant AlG r-Lh E61.5+ `l3 f,9(S Firm Name,if any Address, City& State The above statute requires that debris from the demolition, renovation, rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. The Commonwealth of Massachusetts Department of Industrial Accidents A office 0llnveseaunns -- 600 Washington Street 7`h Flo g or Boston,Mass. 02111 y'Workers'Com enation Insurance Affidavit: Buildin lumbin Iectrical Contractors nameeI^TC�Ct address: city state' i���� Am �� U phone o It 7,P work site local on(full address): l� 1q,4+- Vr r�'� 3�(61K M - ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel ❑ I am a sole proprietor and have no-one working in any capacity. ❑Building Addition _- --- - -g—Lam an-employer-providing-workers' compensation-for myemployees working-on-this job.-- - - companYPaine dor �4 'IJ1."s-J 7' a s ,c 1 � ,(J�JC�Wu � �ri��� fht ti a ix �g'ff5E3 d �i d F� address: .R OR ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: Company name address: ,. . �T., IT fi :}.✓ r 4p { &"F '4R, :. In .. : . ., V w'T .�. Y `.., 1 .r>. ,, .�>E ., -v.,. Ffix�A•a,.m§., Isms Ni company namr. t , address.• city. -i 7'," + ;:: 1 Kt £✓?.°,?' Ft1I'w ,. ab"# +iEhi 't •', { '• '"x', d • fir o � -n in x :.•.a .� +}r^ a.;,y 'i< er,v.�a � ,nt..im ii,°i a „=' Failure to secure coverage w required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a One up to S1,Soo.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once or Investigations of the DIA for coverage verification. I do here erdfy under rhe pains and penalties of perjury that the informadon provided above is true and ccorrect{ Signatures Daze /26-/C - c� Printname Phone g47ir,- 70C Z official use only do not write in this area to be completed by city or town official city or town: permit/license a ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑selectmen's Office ❑Health Department contact person: phone a; ❑Other I ,,u S,,, 21M) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the`law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state ar local-licensing agagency shaltwithhold-the-issuance-or renewal of a license or permit to operate a business or to construct buildings inAhe commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation 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. U City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryouto fill out in the event the Office.of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitilicense number which will be used as a reference number The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office et hN83119e111eae 600 Washington Street,7i°Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 �J f t if — ,._ rioTlyan3iru L_7_T973Zh �5:ft S©9(/8T, 02;'18;20115 11:52 5782077217 1fV I L�IKH I iul+ 3 i 450.116ME N{T4l ' A I E / � I � n18Le9A4 a i I � I I �%ilfl r l UNIT #9 1'2105t?UAF�EFELTacttoEi' L-y � r:.oazi :,yr .;.�..: authort:; jr=iseist_z_ - CdTY oM'A,-:, =',i_'a...__. Fri'::mo ,J::1;:, _ �.`U ..�„ s,.. v1J ,�J_� . EY — PLA:�Apr . - n0•.. � LC'%rte{ � .I v .� i c , 5'E"L 617'L'7 - INTEGRATION PAGE 03/04 11: 52 �I �� vcu�uwrrz �I I �I ' I Y' I CJ �Imw o ° �A/— CL CITVOFA BY lON,POR APo�E WI7y THE FIRE COPE. s. COMFL-q_!t C al•. -- IPJTEGRATIDN F'ti�iE Eid/Ct4 E1°11S!.2rlCl5 11:52 9-82817277 ¢r[uzi+eworea L Icrt(�alG1l M6 I a f n I i I J � ' � I i I a '1V UNIT # 3 THIRD FLQQPLAN a 3 *10ST-SEfILE� APPROVEO BY T+IE .WSPECTD B PFWR TP A_PERMIT.BEING GRANTED / CITY OF SALEM No. '� Date 7 �� s�y Is Property Located In Location of the Historic District? Yes No_ Building Coe'f r Is Property Located in the Conservation Area? Ya No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, epair/Replac , Other: ? a a„Fl,,s "v =aj.9 PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: � f Owner's Name ab r + ar C �V-Cl Address & PhoneW4s� �, r^fit 2k, I X71 ) 792- q SIj y Architect's Name Address & Phone 1 Mechanics Name A." eSF- e c C 4 4 Address & Phone -7 7 CC K q� tS l ISE . (g7g 1 714 ' 2732 what Is the purpose of building? v r r✓� Material of building? S�o K�V If a dwelling, for how many families? Will building conform to law? Asbestos? Estimated costI Z J cUy License o N A State License It 1... S _71L Barge Improvement Lie. i Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE I R�zi'vlioLkc C&Md 1 �acr Oo Pc t'�f � S jsC'( +1 . V,giA II Q✓blmu q a5� vel V- t 5 t Gr P b�Att� . MAIL PERMIT TO: 7 r ) .1. No -0 APPLICATION FOR PERMIT TO LOCA ION PERMIT RANTED �C OSS APPROVED k�LIZI ECTOR O UILDINGS i Results I Page 1 of I Licensed Contractor Look Up Select the search method: I Name i Maximum number of matches PTE Enter Search terms separated by spaces. jEon Pike Select Search type: AND C OR Search Search Results City/Town Name Type FLIc # Restriction Expiration Street State Zip SALEM E,1BION R CSIH 00 12/26/2006 77 CONE RESS MA 01970 Total of 1 Records matched. Back to Home Pa!e BBRS Privacy Statement o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1 SALEM, MAO 1970 TEL. (978)745-9595 ExT. 380 FAx (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition - - —of-Building-Permit#-- akl-debris-resulting-from-the-construction-activity — governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, SI50A. The debris will be disposed of at: %Uo� 3v CroG aktw / 5�,A o H Ud Location of Facility Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant (( s Firm Name, Wany Address, CityA CityState above statute requires that debris from the demolition,renovation rehab or other The abo eq n, , alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. f The Commonwealth of Massachusetts 3� _ ? Department of Industrial Accidents i� B/flee011mrestltlatl9ra 600 Washington Street, 7ih Floor Boston,Mass. 01111 a� �-'��•lWorkers'Com enation Insurance Affidavit: Buildin lumbin lectrical Contractors name: /vow L- na�nN� JCrry Pyr 04- Cr> address -7 Cc,i,, city ^ state: etj 1 zio- 011-7c) ohonc# (6(00 741 - 277 wgrk site location(full addrecs)� \ rh r 0E �v°�•li to V q d p ,- Sl S1i k /'IQ Y Nr ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ----- -- -E] Yam an-employeFprovldttlg werkers' compensation-for my-employees working on this job eomoan�name: a\4knlE �'«e �`S_fC t 'a CC'S a+•" sdear ra address: 11 Co, n 02, city: �a.\-r�. _ `' & rt., 't ,eek marl iho1" lra+'Z.� 7N` =fta• „a'" II Instlr�,�g� r�kC'V.s+•v. I I `r4V �e,l.sfi5' J- V�S ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comtmnv name• address: . 0. j Y y'".R;.:. ', ?i k'•..:.rtN `kA'1a. ly ,YiITW,L'�, •�.. s � fib'-�} '�}�Ay4J��vhK5�M�* ;,� i} rap mtl - eomtldnv name. address: r , "'s` ✓. x d S r.xXN.�nit,� , yXkTI,'�^F.3++3•M; ... lw Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or one yean'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that s COPY of this statement maybe forwarded to the Office of Inveaugatione of the DIA for coverage verifiratlon. I do herebycertify ains and e jr under thepains p allies ojperjury that the information provided above is true andcorrecC Signature •'�'c^- 1f Date 317k— Print name No ft Phone# 721 7 41 3-/ official use only do not write in this area to be completed by city or town omcial city or town: permittlicense# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Omce contact person: ❑Health Department vrnuv Sept.2(X)31 phone#; ❑Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local-licensing agency shattwithhohtthe imuance-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,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation 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 I Accidents. Should you have an questions regarding the`law"or if being requested, not the Department of Industrial Y Y you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns 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 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: The affidavits may be rets med to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Investlpadens 600 Washington Street,7'"Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406