17 GROVE ST - BUILDING INSPECTION d
i+LAM Mill T-BE fiLf i3.APPROVED BY T*IE
W5PfXTD1- ,PFWR TD A.PERMIT .B,EW G GRANTED
CITY OF SALEM
No. ,�:>� '� '�� Date
�H NINE
Is Property Located in Location of p
the Historic District? Yes_No_ Building / 0-p t}C
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace O er: .4 DA- T- e-J
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:
Owner's Name JT`rn 1(�Aene2
Address & Phone /7 6n?mvc S7 . SA/.e�% (91bP) 7y/- >9kl�l
Architect's Name 040.4�> TR ca . .•rl1
Address & Phone S7Vea - QxAfE
Mechanics Name k mie 1 Rke j ' 4
Address & Phone // wgwiJ�un at4 C7-• 54l4r,What is Is the purpose of building?�Q/JQ4 i¢"+•`Az /�1i�STtR /3a��eo�
Material of building? cuomQ If a dwelling, for how many families? f'
Will building conform to law? Asbestos?
Estimated cost 106. "O City License# A State License #
Home rovementaz
1 yI'll %1,6
� Lic. /I Sao X
�s twa ��\ Signature of Applicant
U SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Ao po o-J X j,S'
up 4 " Lr/ecreJ�.¢L seey�ce . .0•��1 Ra..ia+uarrt
!!'Talc¢.✓ -
MAIL PERMIT TO: 14-rzk 0'�e4j,'e wmaA 6k2d C 7T
S/i/ew� MR.o/9?-0
No.
APPLICATION FOR
PERMIT TO
2 X 2-3 y .1 , ` ;
M_
F LOCATION f s
l 7 11 vve
� L
PERMIT GRANTED
f
APRROV D �
Y _
INSPECTOR OF BUILDINGS f
i
/57%,..-,)
ci�y OfSafen Massacfiiusetts
"ire Department
� P 48LafayetteStreet 29 Fort Ave.
-obert lf?Turner . Sa[ern, Massadiusetts 019 7 0-3 695 Fire Prevention
Cho Tel.978-744-1235 Bureau
978-744.6990 Fax 978.745--4646 978-745-7777
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND THE SALEM FIRE CODE, APPLICATION IS HEREBY MADE FOR THE APPROVAL OF PLANS
AND THE ISSUANCE OF A CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT BY THE
SALEM FIRE DEPARTMENT. ( Ref. Section 113.3 of the Mass. Bldg. Code)
JOB LOCATION:
OWNER/OCCUPANT: _ T.` n l�fl e&L&e
ELECTRICAL CONTRACTOR: i�'� S 4 7:a 20 �IP-Li7QrG
FIRE SUPPRESSION CONTRACTOR: PtS�9 Ta Qo L'IGcT2.'�
SIGNATURE OF
APPLICANT: «<///��:: PHONE : q 2K
ADDRESS OF APPLICANT: CITY OT J
1/ Gs�cnlJ/Jc,.Q,/T % TOWN:
s"
APPROVAL DATE:
Certificate of approval is hereby granted, on approved plans .or submittal of
project details, by the SALE14 FIRE DEPARTMENT. All plans are ;approved solely ¢
for identification of tape and location of fire protection devices and equipment
All plans are subject to approval of any other authority having jurisdiction.
Upon completion, the applicant or installer(s) shall 'request an inspection and/or
teat of the fire protection devices and equipment. (ADDITTIONAL REQUIREMENTS,
SEE REVERSE SIDE ***)
E
NEW CONSTRUCTION.
P
PROPERTY LOCATION HAS NO COMPLIANCE WITH THE PROVISIONS OF
CHAPTER 148, SECTION 26 C/E, M.G.L., RELATIVE TO THE INSTALA-
TION OF APPROVED FIRE ALARM DEVICES. THE OWNER OF THIS PRO-
PERTY IS REQUIRED TO OBTAIN COMPLIANCE AS A CONDITION OF
OBTAINING A BUILDING PERMIT.
O PROPERTY LOCATION IS IN COMPLIACNE WITH THE PROVISION OF CHATTER
148, SECTION 26 C/E, M.G.L.
EXPIRATION DATE: z � Q
SIGN TORE OF FIRE OFFICIAL
FEE DUE: UNDER 7,500 Sq. FT. 30.00 F'O}M'• 81 3/98
7, 00 SQ. FT. OR LARCEK-- $50.00 1,;2zR
CHEC
OCT-14-2003 02:25PM FROM-CLEMENT ARCHER INS. AGENCY 9''IS-922-9276 T-031 P 001/001 F-635
..........
DAlE(MLl(0QNY)
11
C)
AQ0&b 199 14 �03
V19"t
PRODUCER' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EWTEND OR
271 CABOT ST ALTER THE COVERAGE APPORDEo BY THE POLICIES BELOW.
BEVERLY MA 01915- COMPANY — COMPANIES AFFORDING COVERAGE
A WESTERN WORLD
W5URED
COMPANY
GRENIER CONTRACTING a
11 WOODBVRY COURT COMPANY
SALEM MA 01970-
COMPANY
p::::;V:11
THIS 16 TO CERTIFY THAT THE POLICIES OIFINSURANCE LISTED BELOW HAVE BEEN 1,'MJED70THE INSURED NANIGDAS0VE'FOR THE POLICY PERIoo
INDICATED,NOTWITHSTANDING ANY FIEGUIREMENT,TERM OR CONDITION OFANYCON7RACT OR OTHER DOGLIMENTwrTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR WAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HOREN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
I
LeI POWMEFFOGTIVE IRCLOYMIRATION
i "OFFIWINIFUNICE POLICY Human DATE(MIN11DONY) CATE(NIMMOtM LIMITS
Q9N3RAL LIAMurf GENERALAcEaREGATE Is2, 000 OOC
X COMMERCIAL GENERAL UANUTY T8I 09/12/03 109/12/04 PROX=t =MP/CP AM3 s2, 000, 000
i CLAIMS MADE OCCUR PERSONALS AOV INJURY 0.1, 000, 000
X OWN EASSCONTRACTORSPROT. EACH OCCURRENCE S1, 000, 000
FIRE OMAdE(Am we ftrel 45 0 1 0 0 0
NED EXP IMY wo pwrQ 05, 000
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
—HI
ALL OWNED AUTOS (BODILY INJURY
SCHEDULED AU CS (Pa PWPPnl
HIRED AUTOS BODLYiNJURY
NON-OWNED AUTOS Tar micom
PROPERTY DAMAGE S
GARAGELABIUTV AUTOGIVILY-FAACCIDENT 6
ANYAU7C OTHER THAN AU. ONLY:
EACH ACCIDENT I s
AGGREGATE(RATE 1$
"EXCIPUS UABILITY EACH OCCURRENCE 0
UmepaLA PoRm AGGREGATE 5
OTH&THAN UMILPAUA POW s
WOFIKEFIS COMPENSATION AND
EL EACH ACCIDENT 5
THEPWF41TOPV IN,GL ELm4sEAsK-POLcYuMiT 1;
PARTN5FSf,.XECUTiVE
OPPICIERSARL I EXCL 94 DISSA"-EA EMPLOYEE S
I OTHER
ob llwrlom OF OPERATIONSiL=TIOKSNEHIMUSr.PECiAL ITEMS
so
SHOULD ANY OF THE AS OESCFUS 99 OJUACELU05 DEFORE THE
WIMIION DATA TdIR F. THE UING c AN. WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN N TICS TO CAM HOLDER NAMED W THE LEFT,
MR. Ec MRS. KRAMBR BUT FAILURE To MALL UCH OTI 3 IMPOSE No ORUMATION OR IJAIRIUTY
P PA ITS AGENTS OR REPRESENTATIVES.17 GROVE ST. ar—Mw—y�lmi U
SALEM MA 01910 [AUT�
HDRUDED EBB
DA ATio mw
NOTE-
THIS PLAN IS NOT THE RESUL T OF AN INSTRUMENT SURVEY
AND SHOULD NOT BF USED FOR BOUNDARY RECONSTRUCTION,
IT IS FOR MORTGAGE INSPECTION PURPOSES ONLY.
N�F
A/0. /3
N/F GR0� VE r
t►•1 96 N N1F
N WELCH
G
/010 W/7 BARN S/.B
2 Sry u/10 \
L4 CK PAR K
a
y "
/99.6 -
�F R/LEY
y
DEED R-FERENCE`
aoc, t / / a a i
PLAN REFERENCE
Beor_ 202
I CERTIFY To MORTGAGE INSPECTION PLAN
THAT THE DMELL N HEREON S
LOCATED ON THE 6ROUNO AS SHOW AND OF LAND IN
THAT IT DOES AWCONFa W TO THE DIMENSIONAL
REGUIREMENTS OF THE ZONING BY-LAN OF
THE CITY OF SALEM MA MITH REGARD SAL EN, MA
TO FRONT46E AREA AND SETBACKS AT THE
O ELLINS SHOW HEREWON IS OT LO ATEO SCALE : I ' = 40' A.4 y'ZS . 1995
MI THIN A FLOOD HAZARD ZONE AS DELINEATED
ON.THE MAP OF COMMUNITY NO. P50102
SALEM, MASSACHUSETTS AS REVISF_D TO
08105185 BY AGENCIES OF THE FEDERAL o 4o Bo /2o Fr
INSURANCE ADMINISTRATION.
o� MICHA spa COASTAL SURVEY
f D. MADSMORTH VILLAGE — DANVERS HOUSE
0 sown N 130 CENTRE ST. — DANVERS, MA
No.3aso9 (508) 774-9450
E35l
DATE PROFESSIONAL L VEYOR
OF SALEM., lYlASSAChW=r- I
{off PUBLIC PROPERTY DEPARTMENT
• •. 120 WASHINGTON STREET, 3R0 FLOOR
< SALEM,MA 01970
$� TEL. (978)745-9595 EXT.380
Itq FAX (978) 740-9B46 .
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
n accordance with the provisions of MGL c 40,S34,1 aclmowledge that as a condition
I Building Permit# all debris resulting from the construction activity
of �shall be disposed of in a properly licensed solid--waste
governed by this Building Permit
disposal facility,as defined by MGL c III,S150A
M -
The debris will be disposed of e T�
t: Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Pe
Name of Permit Applicant
6lr�,.,•'C2
Firm Name,if any
// u�oo.DL i/ C' T
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 cM, S 150A, and the building permits Or licenses are to
indicate the location of the facility.
/ 1
ommonwaaft of
�<Par(manf O as —Attia<n10
S 1 n 600 ryWaalat�irui
James I Camaad Uoslon, ///asuc�irwtts o21 1 1 _
Cornrnrssa><an
Workers' fC�o�mpensation Insurance Affidavit
4aa.....rnrrra<)
wither principal place of business at:
c u� ,� �i9
tcaods.awsb)
do hereby certify under the pairs and pcnolties of pe stry, that:
1 am an employer providing workers' compensation coverage for my einployew working on
this job.
insurance Company
Policy Humber
I am a sole proprietor and have no one working for me in any opacity
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Insurance Company/Policy Humber
Contractor
insurance Company/Policy Number
Contractor
() I am a homeowner performing all the work myself.
I wro<ruanC wt a cool of[hit wrm�t w9a b< iory aroee w rh< Offc<of lmoccaaern of rh< DIA for co.<rarc re<ikadon VW out faiur<m"CCC
co• arr v r<oa<ro unacr S<cdoc 2SA of MGL I S 2 cm kao to thr'rrooyuon of criminar o<rwu<s corsadnt of a fee of aM 4l'SODAO and/or o<u
r<ars' iraruonm<nt v +.<0 of Ci<i o<naldo in nc� +orrn or a STOP WORK ORDER ano a fru cf S 100.00 a an st
day of oGrr r � e®3
Signed this , �`J n
�J
�iccrscc/Fcrmittee building Gepartt*+ent
licensing Board
Seieczmens Office
Health Department
401 , ��5, �De, 17t
I�