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0023 GLENDALE STREET BPA-08-2071 No City of Salem ward APPUCATION FM PERMrr TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT IhOPORTANT-MP/cwt to conWioft ai ttanu In soctiona:6 K 14 M and a. L AT kOCATK" 2� I nLE1t1,Q dL - 4VC aM — LOCATION OTRGM OF eErA*JE+ AW BUILDINGjC1O"r"EEn Fnoasernan LOT 91180IV1s1 M LOT BLOCK SIZE _ A TYPE AND COST OF BUILDING -AN applkants compete Pert A-D A. TYPE OP IMPROVEYEM Q PIWPOSM UM-FOR-DEMOUTIOW USE MOST RECENT USE 1 ❑ Ilwr any RaaldanEN Nminaldanllal 2 ❑ AOWllon ry Maidmn WAWm rbw oinaw 12 ❑ Ona WWY 1e ❑ A1laawnald.noa�tlonsl uNb aedaq l ant-n ten D. 13) - 19 ❑ CNeJ Il.alhar Mligms 13 ❑ TWo a mon tmaT-Entr number 3 Aaantlall(Saa 2 above) d uWl — 20 ❑ trbVitr a ❑ Repair aolaow r d 14 ❑ TwaWa hoK nlotl a danW wy- 21 ❑ Pwkiq 9ani &ll1w number or UAW-_..._-_- 22 ❑ Swvim alalfoll vpM gwmW 3 ❑ Wnekm h--W&I y Madwd.1,Mat/Wll.bw 23 110804K mar d unit inOuildbp in M a 13) 13 ❑ QwMw 24 EqOefoll bWft Pnta.larlal e ❑ mm"(ralocatlon) 16 ❑ Cwoal 25 ❑ Public uMV 7 ❑ Fouldaft aay 26 ❑ ad"as-v oew e&xwwrul 17 ❑ Otlw•SpNy 27 ❑ slant.m.m oo IL OWNERSFaP se 2s❑ %r+46�s ivalle +nstauaon, 8 ❑ P stwuli idNduaL aaPaaaorl,nonpaw 29 ❑ OVw-SP.w e) - 9 ❑ Public(Fvdvr,Ste,a Weal 9a«ra++an - C. COST /anr Cw9w NaraalkidnaY-Describe i1 daW PraOosad uaa d buid"M a4.lead orccDaai9 DMr�. .4 nadl m shoR iaadry buk&V aI haspilK alwnantry tent'saeardny sclsad.eor9®. 1 O. Coal of inproveman ---_-_--- >, oarodlw schooL oa*kv yaraw for dwea wa'lent renal ollb buaasp,OMM buddb,. al ilduMM dull Y uaa d"a"bLAdkq in b"V cwl9sd.enter aaoesad uaa 7b be lnsnUad but nd kWA dw in ow MOM case _... a G Meati3O,air candalpni,p..--.------_-__.-- 040 -- 6 00w laMbr ra ,ale.,..------------_—.-... rEE- TOTAL COST OF IMPROVEMENT !7• SELECTED CHARACTERISTICS OF BUILDING For new buildings and additions, complete Part E-L,` demolition, com to on Parts J A M aN ofAers ski to/V PR INCUTAL TYPE Of FRAME F. PR TYPE OF HEATH FUEL G. TYPE Oj SEWAGE DISPOSAL L TYPE OF MECHANICAL 30 ❑7��r(w'r be.r W 3s cr ao lrJs/Pllfa a Odvat oanPwry NM r�M be}tanw Y 31 IL Kama 3a ❑ Or 41 ❑ Pri.W(aapba vet ale.) "nOry,,�' 32 Struetvsl algal 37 ❑ ElaelleJy aA LJ ' 43 ❑ 33 ❑ ReiAacad 1,cmft 38 ❑ Coe K TYPE 0 ATMt SUVPIY ,I"awv by w aW-dan r 3e ❑ Othw-Smc*y 39 ❑ OVw-Sw* e2 ff Public a w%ar 0WIP V 46 ❑ tea .7 V, 43 0 PrNat(.A coon) C A i o.rrrarow ?i hA DEMOLITION OF STRUCTURES ,s TOW,o ors real d 4"ana Hat Approval from Historical Commission been received r+oa>,bisad m wary 3.�� for any structure over fifty(50)years? Yes— No- 5a "w WM ar.a w 2 Dig Sale Number K rauaeer or oas srRrcT vnacwa srsccs Feat Control SIEmlowd ___._._...-.___._._..___...___.__.._.._ HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? sz OAdoer.---------------------__..._. Yes NO l FlEswerndl OLADWs orgy Wetef. Ele�'iG sa. G Fufi_—___._.._.._ Sewer: 54 Ma ear o1 DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED °ad ""a Farear .-----__---__-- BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic OiSMW Yes— No (M yes Please enclose docwtentatbn from Hlaf.Corn) Conservation Area? Yet— No,/ (lf yes,please enclose Order Of Conditions) Has Fire Prevention approved and stamped Plans Or appl ? Y No— Is property located in the S.RA copica Yee_ No Comply with Zoning? Yes— — (ll no,enclose Board of Appeal decision) Is lot grandfathered? Yee_ No— (if yes,submit documentatlonld no, submit Board of Appeal decision) If new construction,has the proper Routing Slip been enclosed? Ye&_ NO_ Is Architectural Access Board approval required? Yes_ No (If yea,submit documentation) Massachusetts State Contractor License * 2 2-Y6 7 Salem license a Al Home Improvement Contractor Homeowners Exempt form(d applicable) Yes— No CONSTRUCTION TO BE COMMENCED WITHIN SIX (6)MONTHS OF ISSUANCE OF BUILDING PERMIT ti an extension is necessary, please submit CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings. V. IDENTIFICATION • To be completed by all applicants' %a" VA q Sd&n .W.md V. St/ea(CM.&V SWP ZIP C X% 'al NO �REb ,d7'C 1v -N©A A ✓ :-esva Cmv:.� `)�jd G�/I� ✓)/J/, ' - t,canr Nn 'tom. ( 1 .wined x ErgrK t hereby Certify that the pr work is 'zed by the owner of record and that I have been authorized by the owner to make this application his authorized and•we ree t .form o all iCade laws of this;urisdicbon i SigraNre of Address A ice' date appf �f �7N���(/d L�• 6 � d DO NOT WRITE BELOW THIS LINE VL VALIDATION FOR DEPARTMENT USE ONLY Building Pem,A number usa Como Building t g Fin Grdrq Permit issued BuAdirV / LAw Lnfdne Pbrmil' Fee s o«.,cwcv tea Certykal a of Occupancy S APPrd're° Drain Tile t Plan Review Fee $ /�✓SP. TfTLf NOTES AND Date• (For department use) „ Aj S C S PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by. Completed by. A ZONING PLAN MANNERS NOTES j DISTRICT USE f FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN-For Appkant Use O N s CITY OF .SALEM V., ) PUBLIC PROPRERTY DEPARTMENT \corkers' ('onipensation Insurance Altida\it: Builders/ContractOrsiLlectricians/Plumbers \ ) ilff.ant Information Please Print Leeihly `.Illlc i lhnulr.. l pp.lnitam�n Llsht dual 1:j TC r g �720 t Wit"tv C'ean1�1 - c'it) State Zip: s4ZEN.t lMi4' Phone4: _ire a an employer'.' Check the appropriate box: Type of project(required): 1 1 nt a elnpluyer with tea_ 4. ❑ 1 :tin a general contractor and I fi ❑ w construction employees 1 full and'ur part-time).' have hired the slob-contractors 7. Remodeling ❑ I a sole e or partner- listed on the attached sheet. ,hip and haveve no nu employees loyees These >ub-contruaurs have 8. ❑ Demolition workers comp. Insurance. y_ ❑ Budding addition working for me in any capacity. 5. ❑ e are a corporation and its �No workers* comp. insurance 10.❑ Electrical repairs or additions required.( officers have exercised their I of exemption per MGL mys 11.0 Plumbing repairs or additions 1.❑ i ys c a homeowner doing all work elf: (No workers' sump. 152, 5 1(4) and we have no 12.❑ Roof repairs insurance required.) r employees. [No workers' 13,❑ Other comp. Insurance required.( •auy,,ppicant that checks box nl most also till out the section below showing their workers'cumpenmtion policy information. ' 11un.co.ners W ho!ubmlt this affidavit Indicating they are doing all work and then hire outside contractors mass submit a new aftlllaYll indicating such. 'Gbnlr:,clors that check this box ntust attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l airs an ensployer that is providing workers'compensation insurance for my employees. Below is die policy and job site infanrnatmn. Insurance Company Name:— .� �.! vye2 6Y 49�`/ E.xpiratiun Date: It/o r7 y Policy d or Self-ins. Lie. q: L(��2. �,. Yn rfA its Job Silc Address: �7..��-tom �< c City, .\ttach a copy of the workers' compensation poBcy declaration page (showing the policy number and expiration date). Failure to sceure coverage as required under Section 25A of SIGL c. 152 can lead lu the imposition of criminal penalties of a tine up to S I joo.of) :u)d'or tine-year Imprisonment. as )%ell as ci%d penalties in the firm of a STOP WORK ORDER and a tine „f up to S'50 tot)a day aullllst the v iolator. lie ad%iscd that a copy of this stdien)ent may he tbnv arded to the Office of Itit c,t _au,nl„d the DI:\ for iluur.mce cot crlge scn ticauon. IF,let hereby sertili• rue,/ th pains 1 ties aj perjory that the utjorrnuriont pr,r, Tided oboe is true and aurrect Dane. G �� ityly It Lre '.. I1r,, Ullieial use only. Do oar write in this area. fa he runrpleted by cify or rows 41hial < itv or I osuh: _. — IYYuinq \uthority )circle line): 1. Board of Ilcallh 2. Building Deparuncnf 1. (ityl sown (lerk J. Electrical ln%pector S. Plumbing Inspector b. Other ContactPervon: _. - __-- Phoneq:_.__ ----- Information and Instructions htl,cue l ii ner.tl I aw, .h.gncr 1 �' ieyuui, Al cinploher, it,pros iJe w%orkcrs :,nnl,cn,ation for the it cnghlosees. I'",'u.lnl to thi, ,tamtc• .ul rutploree I, dethned is ih er\. per,ou tit the ,cl,i:e oI .unnher under.ors uonlrJet of hue. or ml,hcd. oral or wlitictl .. . emplurrr I, dctiucd as. '.uI f1di\dual. I,.utr•cr,hgr. .t„oe,ation. „a-p,,ranon or othcr lc_JI cants. or III Iwo or more ,•t the f„I: cn_aced in a joint :m,:ipn,e. and "WIL1,11119 the legal reprc•,cntuti,e, of a dc,ca,cd cutpl,„er, or the ...cner or trace ot.in uldl,iJuil. paunership, a„o:Iatwn or other lcwl cntln. cngllo,Inp cnghlosccs Ilowcser tile ,••.,ncr of a Jwclhng hind' bah nc not :pore than Ihrce apartments and who reside, tf:crctn. or the o::upant of the Jw ciSng lLnl,c ,I i n other who enlph", pervon, to do matntcnan:e. :,,nmrucnon or repair Durk on ,u:h dwelling house .r .,n the __tounds or hUddtltg appuucn.mt I!:etcto ,hall not he:au,c of,u:h emplos men( he deemed it, he an employer.'. \It IL :hapicr 1 y 1. @_'S(If,) also ,tate, that 'csery state or local licensing agency ,hall withhuld the issuance or renewal of a license or permit to uperate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable es idence of compliance with the insurance coverage required." \,I.huonJlly. %IGL chapter 152, 7_s5l'(-I ,rates 'Neldlcr the :onunonwealth nor any of Its political suhdlsuwns ,hall enter into any contract for the per tomnince of public work until JcceptJb IC es Netter of :oulp I I a tier %sith the insurance I cgunentcn is of this chapter have been presented tothe contracting authority." ypplicants Please till oaf the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contraclons) ninlef s). Jddress(es)and phone numberls) along with their certificate(s) of insurance. Limited Liability Companies ILLC) 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 dues hive employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their ,elf-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Of file affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please he sure to fill in the permit,license number which will be used as a reference number. In addition, an applicant that must submit multiple permadicense applications in any given year, need only submit one affidavit indicating current policy inti rmition (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or tow III.- 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 fix future permits or licenses. A new affidavit must be tilled out each y car. \\here 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 IcJ,cs etc.)said person is NOT required to complete this alfJav it. Ilie ()thee of Imesflgations would like I„ think you in advance fix sour cooperation and should you base :thy questions, plca,e do not he,Itate to gl,c us a .all. I he 1),p.0 Inwnt s address, telephone and tax number: The.Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 If Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM ' *` PUBLIC PROPRERTY ;;;-W DEPARTNTENT I'J : I F K;" ' I — 'd .,i gt I_'C A N,I ID.i. ONSI31:1'T 0 SAS I \1, %I.\,i\, i .i 1 I I: '/'8-'1 i.'1 j4+ • I`\Y: ';,4 74:-'t.441, Construction Debris Disposal Affidavit (rcyuircd lbr all denwlition and renovation work) In accordance itll the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit A - is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c t 11, S 150A. The debris will be transported by: AVo - CAQfIyCs (name of hauler) - I he debris will be disposed of in -- ('dine of facility) >�/cttL�bN � V 911. �. (address of Ihcility) --- signature � ' to tit applieatt 6 a� ._ date „i,��.,::,.•, it