26 HARDY ST - BUILDING INSPECTION (3) f MtlSt4111E fNA0 MAID APPROVEo BY TW
J MCM-Pr110t W A:PEBWT BEING GRANTkD
CITY OF_SALEM
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Permit to:
BWLLDINQ PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Instal Siding, Construct Deck, Shod, Pool,
Rspafr/Replaoe, Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The urtdwe*W hereby applies ffor�an permit to build aocor&V.to the,foll mft
Ownees Name Mayt i- Lon 01,11-7
Address i Phone 19 G��-ox (PYA b� ml-)1("a
Architect's Name Jd `
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Address i Phone R7�)qa 7—7Sb 1
Mechanics Name
Address i Phan f )
whd is tea p qmm it WNW Ig.5aw C.,-e—
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90.. Ialsw•aarst �
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S re of Applicant
SIGNED UNDER THE PENALTY'
OF PEIYLIRY
DESCRIPTION OF WORK TO BE DONE '
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MAIL PERMIT TO: l 66 lles - PWAAD Jjv --Afw S
APPLICATION FOR
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LOCATION
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PERMIT GRANTED
19
AP7VfD
INSPECT OF BUILDINGS
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
.A 120 WASHINGTON STREET, 3RD FLOOR
1 SALEM. MA O1970
TEL. (976)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
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,S 150A.
The debris will be disposed of it Ll( ,�
_
) e10-rr� a1 ct�Q
LSignture
Location ofFacility
of Permit Appli Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
SU6-0— Qn Oe-
Name of Permit Applicant
Firm Name,if any
p e � a� n
� I,� as �(�., u&S
Address, City 8r 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, S150A, and the building permits or licenses are to
indicate the location of the facility.
s
The Commonwealth of Massachusetts
y ; _ Department of Industrial Accidents
wee
hingtoNestl et, 7 h
� 600 Washington Street, 7tb Floor
3 Boston,Mass. 02111
Workers Compensation Insurance Affidavit: BuildingTiumbio lectrical Contractors
dre u q/
cit \\ lstate: �^ livoig A phone#
work site location(full addressl� tY� C77Lt C 1 .1 l�
❑ I 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
❑ I am an employer providing workers compensation for my employees working on this
1 job
A(i' * .
yV
rWL, `
�� e u*• • d E V, - J f. x *i +'`-, 'F+n'L
city: r Y oa'hbne°F 1ltfef+u i
*' ��54 ri' yyvY` '�'.'.
[ am a sole proprietor,general contractor,o omeowner(ct cle one)and have hired the contractors listed below who have
the following workers' compensation polices:
commmv name: '
address: ' •"
R
`- a x ^+# '✓n" "YfuTtc+SM`:w+K aI' P v A,
.3 . .� ? Pit += .t�#' � sxi
Com_RSaV name: ,. " <, ,5:- "� +. ,
i _ ter, < -
.y.. n. •.5 �, aY, °$ �x+c S i 4 xF1n"' E4 ,� .cw a cdz5i`:1* s,�-ri9R4�9�
Failure to secure coverage m required under Section 25A of MGL 152 can kad to the imposition of criminal penalties of a fine up to SI,41)0.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this state at may be forwarded to the Once of Investigations orthe DIA for coverage verification.
l do hereby cert� under the pains OdW nafttes of p dury that the information provided above is true and correct n
Signature Date q 1 c�f/�t„){�rQ�-1
Print name 'ram .(lII Phone#
official on only do not write In this area to be completed by city or town official
city or town: permit'licenw# ❑Building Department
❑ []Licensing Board
check if immediate response is required resp
❑Selectmen's Office
❑health Department
contact person: phone#; ❑Other
Devised SeP�20 n)
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i'
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
MITT ROMNEY ELLEN ROY HERZFELDER
Governor Secretary
KERRY HEALEY ROBERT W.GOLLEDGE,Jr.
Lieutenant Governor Commissioner
DEP File # 064-0390
RE: NOTIFICATION OF WETLANDS PROTECTION ACT FILE NUMBER SALEM
DATE: 3/18/2005 10:35 AM (city/town)
The Department of Environmental Protection has received a Notice of Intent filed in accordance with the
Wetlands Protection Act(M.G.L. c, 131, §40):
I
Applicant: Mark & Sandra Connelly Owner:
Address: 19 College Pond Drive Address:
Danvers, MA 01923
LOCUS: 26 Hardy Street
IF CHECKED,THE.FOLLOWING ITEM(S)APPLY TO THIS NOTICE OF INTENT:
A._(X)This project has been assigned the following file# : 064-0390
I Although a file#is being issued,please note the following:
C.Q Other Regulatory Jurisdiction
L Q Application has been forwarded to Waterways Regulatory Program to determine if a
Chapter 91 License is required.
2. () Applicant is advised to forward a copy of the Notice of Intent to the Corps of Engineers
for review(call 1-800-362-4367 for information).
D. ()401 Water Quality Certification
The project described in your Notice of Intent requires a 401 Water Quality Certification
from the Department of Environmental Protection and may require submittal of a 401 application
form. See below for further details:
1. Q Based upon the information submitted in and with your Notice of Intent a separate 401
Water Quality Certification application form is not required. The Department has reviewed
the plans submitted by the applicant and finds that there is reasonable assurance that the project or
activity will be conducted in a manner that will not violate the Massachusetts Surface Water
Quality Standards,provided that:
a) the applicant receives and complies with a Final Order of Conditions from the local
conservation commission or the Department;
b) The Order of Conditions does not cause the loss of more than 5,000sq.ft. of bordering
vegetated wetlands and land under water and/or the dredging of more than 100 cubic yards of
land under water;
This Information is available In alternate format.Call Aprel McCabe,ADA Coordinator at 1-017-556-1171.TDD Scrvlce-1400-29&2207.
DEP on the World Wide Web: hdp://w .mass.gov/dep
I
c) any loss of vegetated wetlands has been mitigated with a minimum replication of 1:1; and is
not part of a subdivision; does not cause the loss of any Wetlands designated as
d) The project is not exempt from the M.G.L. c. 131, §40-the Wetlands Protection Act;
Outstanding Resource Waters; and does not cause the loss of any salt marsh.
Therefore,provided that the above conditions are satisfied,the Final Order of Conditions will serve as the
Water Quality Certification for this project. This does not relieve the applicant of the duty to comply with
any other statutes or regulations.
2. Q Before the activity described in the Notice of Intent can commence, you must obtain a Water
{. Quality Certification form from this Regional Office. Please complete the enclosed 401 Water
Quality Certification application form and file it with this Regional Office for review.
3. Q Your project involves dredging of greater than 100 cubic yards of material or requires a
i permit from the Federal Energy Regulatory Commission for work in "waters of the
Commonwealth." Therefore, your proposed project is subject to 314 CMR 9.00 and requires a
Water Quality Certification. Please complete the enclosed 401 Water Quality Certification
application form and file it with the Department of Environmental Protection,Waterways
Program, and One Winter Street,Boston,MA 02108. Contact the Division of Waterways
program at 617-292-5655 if you have and questions.
For more information please contact: Mr. WAYNE LOZZI at 617 654-6681.
Cc:
Conservation Commission: Salem Conservation Commission, City Hall 1 Salem Green
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