8-10 HAWTHORNE BLVD - BUILDING INSPECTION (002) 1
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CITY OF SALEM
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BUILDING PERMR APPLICATION FOR:
Permit to:
(Cirde whichever apply Root. Remo Instal Siding. Con tract Deck, Shed, Pool,
Aw — �lr�.ld3G z�le //l Wand Lei /� Eat o s+
PLEASE FILL OW LEGIBL i COMPLETELY TO VOID DELAYS N PROCESSMq Cl
TO THE INSPECTOR OF BUILDINGS: '•
The undweigned hereby applies for a permit to build accord0g,to the,following-
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Owners Name �}
Address d Phone l9' /O 4LIJ,,.e 1(IX
Architect's Name
Address d Phone
Mechanics Name
Address Q Phone ( t
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�kL4 PmWRY THE PENALTY
DE8CRIPTION OF WORK:TO BE DONE
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MAIL PERMIT TO.• 9 le) /-7lUd
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CIM N UO J0013d
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The Commonwealth of Massachusetts
Department of Industrial Accidents
y office MlOYestl adm
600 Washington Street, 7rb Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit: Buildin Plumbin lectrical Contractors
namz: /76—o651 /14�
address:
IA _�j t
city /``lGetl-mac_ G ,(state,�//r �'7— 9 zip D 7 phone#
work site location(full address): C� — /d n mac✓%ct-Diet` Igj U6�(
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ElKemodel
am a sole to rietor and have no one.working in any capacity. ❑Building Addition
❑ 1 am an empioyer providing workers compensation for my employees workingon this lob m a
Coin ,r:'c° s''.�'" `"
city r.K• q" '4.^k"'.%5azz.#+�f" e'6n °aar `�y7 �t' ,�,�*h+ •` as
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rBnea
0 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:
company name:
address: .a
city phonet .
,:✓Sy, f - 7 a3 ?�: > < vr..f n- rjryy s• i x a� y. y i._ ✓^
I ran' yzRet s}'• it s:+§' ypon c: v - �,'. s„3y'�t rr ^+?Yeniti7s- &M.1i55++4:rod so-ky+�9^fius nC k.F'i Yv a'"x "�'-•«;< A `-f;c '� W + :io
a T'si
company name:
4
address: t a r.� :; . .' F sr' ��.i ��dr'
. . � s�.�.
Failure to secure coverage a+required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a rise up to S1,500.00 and/or
one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Rue of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify the pains and penalties of perjury that the information provided above is true and cornf cit
Signature Date 5 / 7 ,:�/S
Print name Phone# O 3 J
official use only do not write is this area to be completed by city or town official
city or town: permitalcense# Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
nm;md s pi.2(9nr
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (976)745-9595 EXT. 380
40 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,S150A.
The debris will be disposed of at:
Location of Facility
SignafiwLaOermit Applicant Daie
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City& 9tate
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.
BASEMENT
UNIT 1
AREA = 509±S.F.
strobe
13. Pull station
a
Bed.
O
61
Both Smoke Detectors
7 (Tlyfcol)
8 ',ng
®® ® Room
Kitchen
Carbon
Manoxwe - Dining
Room
❑ fl shone
Pull Station
O
Knox Box e"
Pane 3
Kitchen
UxIng
en
R.
Roam UNIT 2
AREA = 1285±S.F.
Dining
Room
strove
1ST FLOOR
UNIT 3 UNIT 4
AREA = 493±S.F. AREA = 1301±S.F.
strobe 55 Shobe
O
d
BeEroom Bedroom
Smoke Moot. 3.9
Bath O (Twil-1) S Study.
LMng m° iud
Room 8
11.2 ].5
Kitchen
Kitchen Dining
Dining Room
Room
Deck
D
7.5' nD® ra.'
BWroom O Smoke Detectors
Bedroom ® ® "g (TYPW)
Living G ® BaOroom
® UNIT 2 Room
Bath
Bath
Bedroom
2ND FLOOR 3RD FLOOR
FLOOR PLANS
Scale: 1'$0'
FLOOR PLANS
FOR
8-10 HAWTHORNE BOULEVARD CONDOMINIUM
IN
SALEM, MASSACHUSETTS
y �
Prepared By
LeBlanc Survey Associates, Inc.hPPR0`1ED
161 Holten Street SubjeeLt° ='p° ( vy x:',-s•
Danvers, MA 01923 au!hcri` ;;' 'r. :,.• U
(978) 774-6012 CI?v `- `� •, : .i _' ..
May 4, 2005 Scale: 1 "--20'
to
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