62-64 HIGHLAND AVE - BUILDING INSPECTION � y� ` � '
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CK �
fL�A1SilAli6��EfN.f��i�lD APPROYEt3 8Y �IE
,ayS,p,�TAJ�,PR1pA 7P A_PEAMIT R,EWG GRANTED
CITY OF SALEM
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No. \�,_ „` ' ��"%' \ oeca l �
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Is PrOperty Located In Location of � � � �
the Histodc Distdcl9 Yes No� Bui�din8 z'-C � �
Is PropeAy Located in �t
'� the Conservatfon Area9 Y�No� S"�'�� �'^Qti_
BUII.DING PERMIT APPUCATION FOR:
PeRnit to:
(Circle whichever apply) Roo Reroof: Install Siding, Construct Deck, Shed, Pool,
epair/ eplace, Other:
PLEASE FlLL OUT LEGIBLY& COMP�ETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned he�eby applies for a permit to build according to the following
spec'rfications: -
Owner's Name � �o � � �U r e�z'� _
Address & Phone 6�����•, �a (�-�� 1���' �`� �� � �
� ; r Arohitect's Name
Address & Phone � �
�echanics Name �eo�r��n \� ac�a ., � '
Address & Phone 20 ���1 s S� `2 (`���) 2-�o aS �`�.
What is the purpose of buiWina9 ��, - a C-_r� :v�.E.r e:c�\
���o� pW���p �}JppS) _ If a dweAing,for how many famNies?�
WIII building coMortn to law? �e.s Asbestos? �o .
E�etea�o� I�a,r�c�o Cnr u��r ►`� °� srete u� � S ��Ql � S�
,
Ha�e Ympravoent � I
rdc. / Cs • n �`��
� Signatur ' pplicant
SIGNED DER THE PENA�TY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�u�(��e� �ue.�.\ s r-�c1 G\:r�u t
`\v�-S�"'J \ IU�I�.� ��+2 hcc7.ac1 H�\c,.S�-aon"�..n r�cVi� �
� �'- ��Vk�S�\ �V� 110.H�. l�.�u(� � i�cJOY �
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MAIL PERMIT TO• - �i1 �¢2 E/Q�
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APPUCATION FOR
PERMIT TO
. /'�fh�o_�%'�• Td �r^,'� .
� � 6y —�
� LOCATION
,
� � --�y ��t��G�.p ��-,
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PERMIT GRANTED '
3� 17 /0 � 2c� �
AP OV�D � _ � � y
�iUP'�v
INSPECT_ R OF BUILDINGS
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ACO�D� 'CERTIFIG'�ATE OF LIABILITY INSURANCE DATE(Mh7/DO/VY)
March 7,2005
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Culver Insurance Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. .
20 Central Street
Salem,MA 01970 INSURERS AFFORDING COVERAGE
INSURED INSURER A:
(�ll1�
Teadaro Ortega dba Ortega's Design& Construction iNsuaEa e: d��
20 Phelps S[#2 iNsuaea c:
Salem, MA01970 iNsuaeao�
INSURER E: I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICV EFFECTIVE POLICYEXPIflATION
' �Tp TYPE OF INSURANCE POLICY NUMBEH OATE MM UU V LIMITS
NERAL LIABILITY EACH OCCUFRENCE $ �0
COMMERCIALGENERALLIABILIN FIFEDAMAGE(Anyonefire) $ 5��
CLAIMS MADE � OCCUF pending 03/17/OS Qj/]']/Q MED EXP(Any one person) $
PERSONAL 8 ADV INJURV $ S OOO WO
GENERALAGGREGATE S 1�OOO�WO
GEMLAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG S I
POLICV PR� LOC
JECT
AUTOMOBILE LIABILITY COMBMED SWGLE IIMIT
ANV AUTO (Ea accideni) $
ALL OWNED AUTOS
. BOOILVINJURV $ �
SCHE�ULED AUTOS (Per person)
HIRED AUTOS
BO�ILVINJURV $
NON-OWNEDAUTOS , (Peraccitlenq
PROPERTV DAMAGE $
(Per accitlenQ
GARAGE LIABIIITY AUTO ONLV-EA ACqDENT $
ANVAUTO OTHERTHAN EAACC $ I
AUTOONLV: qGG $
EXCE55 LIABILITY EACH OCCURRENCE $
OCCUR � CLAIMSMADE AGGFEGATE 5
$
OEDUCTIBLE $
RETENTION $ $
WOHKERS COMPENSATION AN� pending 03/17/OS 03/17/06 TORV L M TS �ER
EMPLOYEFS'LIABILITY
E.LEACHACCIDENT $
E.L.�ISEASE-EA EMPLOYE $
ELDISEASE-POIICVLIMIT $
OTHER
OESCfiIPTION OF OPEfiATI0N5ILOCATIONSNEHICLES/EXCLUSIONS ADDED BV ENDORSEMENT/SPECIAL PROVISIONS
General Contractor �
CERTIFICATE HOLDER ADOITIONAL INSURED;INSUHER LETfEF: CANCELLATION
SCOLt aYi TIDa DUI'B�)0 SHOULD ANY OFTHE ABOVE�ESCHIBEO POLICIES BE CANCELLED BEFOHE THE EXPIRATION
6Z-�4 HIgf1�9lld/1VCpU0 OATE THEHEOF,THE ISSUING INSIIREH WILL ENDEAVOfl TO MAIL _ DAVS WRITTEN
Salem, MA OII�IO NOTICE TO THE CERTIFICATE HOLDER NAMED TO TME LEFf,BUT FAILUFiE TO 00 SO SHALL
IMPOSE NO OBLIGATION OH LIABILITV OF ANV KIND UPON THE INSURER,ITS AGENTS OF
REPflESENTATIVES.
AUTHOR FEPRE �
ACORD 25-5(7/97) � - 0 ORD CORPORATION 1988
1
r �
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). -
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights ro the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S(7/97)
.
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�'� The Commonwealth of Massachusetts
���y` 3 Department of IndusJrialAccidenLs
;� .-. � -= Bfl11�9//OYBS�BtlOBs
� �_ -- 600 Washington Streer, 7`"Floor
� -'' � Boston,Mass. 0211I
�tu��Workers'Com ensatioo losunnce A�dsvit: Buildin lumbiu lectrical Contractors
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name� 1 enC�(7�C.r—� `�,. Q �� G h . .. �
2-o `�i� ` i �L
citv S�'�'w� state: �C9.Sf ae; O\�I�O �hone# ��`t�/ 21 O �-S s�
wor si[ lo I s �
❑ 1 a homeowner perfortning all work myselE Project Type: ❑New Construction emodel
1 am a sole proprietor and have no one working in any capacity. ❑Building Addi[ion
❑-1 am an empioyer providing workers'compensation for my employees workmp,on th�s�ob
' *� . "' -� � 9,\"X�s"� 4 �,�.y� ,0y ��>�•� a -.� a m rqr�!
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comnanvna e ;� 5 3 � �' �r'� S t�. c; S�'Ca PJt� �-�k ` '`
Q 1 t� 7,�� a�.,, �, �. ��,^f `$cm�.Ly ' �* a;,z ,+""� � *v�-� ���r`�J
addresa:� Zo . �� PX D S S�� � �' .�Z .n.� 4`€�,r r '�` '�}.aA� xe 3.�.a� r - ,�. �
'a s,� �� .�p � ,z a .am�`rj7x 4y S� ,�r :�
Citv: S�'P�+i.-�`,^ ;�4 Se�k�r� .'�' -�Wr��'s� ��1�� 'd�'C�'�'�,Qn�'� tt�
�� � � � . - r '".:. " .'x �, x '"
n I y :: `
insuraecern. `UIV.(+C' .. ,.Q�SUICw,...n2 ��J� �. oolievlk' •»h G!�!��ciS.•:`w�a`�"r�*�. `,f�� "� ��.
❑ 1 am a sole proprietor,general cootractoq or 6omeowner(clrc(e one)and have hired the wnVactors listed below who have
the following workers' compensa[ion polices:
comoaav namr.�� '"�
. . _ . � . � � - . . ,s,, � ,
addresf:
e', a
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``.�r;'� +�''��
�� n��� A . �,�.'". ^s .�� a�� 1�.,�.'�"*"-�€s..`�'r�. " 4 '� ,{
. j , . . ... ' .. �,.4,'�a.� °�,�a tA',','.�at..w'i',+��'k�i''��ij6s�Y �w��'t"�, ��4��L;'
� C0111D80V 081110• � ' �
addrw> .. ���, "*�'+ �^„�* xR" �:�'�,"�,sr�''4�'=^� +.#�� � ��$"�a� ,� �
+ . .� k , '�_k ,� '�°�. :.r �a�k,�, ..,
-`,a tx ^.�. .'.,- !T "Y a �eF" t'..c�.x:,,{��'a �"'-��f�q.�'i.v r '�'e ko „..r� �u?e° x � i� v= 2 �
C�(�: M�. •x, . '� i :, } rt..r"el f+AdY �+f�dY'�+k1MBOl��i1C1'45��i ���1�'"S"C��t�+t+t '�,r .
s � a e.!.r P r 4"3r^'�xt` .�+ `�� '�Ar��'S�,r_
� 4 "9, 's� . 1.p s`��yry� °- �fi��7�i�fY'�,>� i.2 � 1^rt. ?ak5`r��'r�.
a�+i,. .�. ��dFi��ESrt+33$����.+�TA�c�'w1}s-v�y+$.+3�2+�1�.Y'' -,�s"h.y'
Faflure to secure coverege es requ{red under Sectioa 25A of MGL 152 cao lad to the impositfou of crfminal peonNip ota fine up W 51,500.00 and/or
� ont yean'impdwoment e+well es civil peoalNn lo the form of e STOP WORK ORDER and a flne o(5100.00 a day agninst ma I ooderstaod thot o �
eopy ot ihu slatemeot may be forwerded ta t6e ORet of[nvestigalioos of the DIA tor covera�e verificatiaa
/do hrreby certify under the pains and pena!lies ojperjury!hw the injormation provided ubave is(rue and rorrect
Signature Date
Print name Phone H
, oRcial use ooly do nol write in Ihis area lo be completed by city or lowo olticial
city or towo: permil/licenx M ❑BuiWing Depar�menl
❑Licensing Board
❑chec4 if immediate response u required OSelectmeo's Oitice
�Healt6 Department
conact penoo: phone k; OOtAer
I![�If[A SCpI.�IMI1)
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Information and Instructions
Massachusetts General Laws chapter l52 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
i 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 apartmenu 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 shail 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 shall wit66old t6e issuance or
renewai 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 wit6 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.
Appiicants
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 sigo and
date the a�davit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, oot the Department of Industrial Accidents. Should you have any questions regazding the"law"or if
you aze required to obtain a worken' compensation policy,p[ease call the Department at the number listed below.
"�'�.: , .
_»;.�`t�.� „ a � � , ,� s , ���_ � . � ��
. .
City or Towns
Please be sure that the affidavit is compiete and printed Iegibly. 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 regazding the applicant. Please
be sure to fill in the permiUticense number which will be used as a reference number. The a�daviu may be retumed to
the Department by mail or FAX unless other arrangements have been made.
The Office of[nvestigations 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.
. . • �
r=,,� . � < ._. : _.. • _ ._ . � _ _ �
The Department's address,telephone and fax number:
T6e Commonwealth Of Massachusetts
Department of Industrial Accidents
OIOce N ImestlBatl�os I
600 Washington Street,71°Floor
Boston, Ma. 02111 ',
fax#: (61'n 727-7749 �
phone ii: (617)727-4900 ext.406
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� .�o ` ' CITY OF SALEM� MASSAGHUSETTS
� PUBLIC PROPERTY DEPARTMENT
� 9
120 WASHINGTON STREET, 3RD FLOOR
�� lar� SALEM, MA O1 970
�� � 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 aclmowledge that as a condition
of Building Pernut# , all debris resulting from the construction activity
govemed by this Building Permit shali be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A.
The debris will be dis ,osed of at: �e c,,.,�A�oT 5�.�-oc1 �a9-�_
Loca�hon o -Facility
!
03- !� - a�
Signature of P t Applicant Date
FULLY complete the following inforu►ation:
(PLEASE PRINT CLEARLl�
�a- � c� e
Name of Permit Applicant -
Firm Name, if any
102. ���qA e� JLQV� �O\Q�.�.-. �AuSS _
Address, City tate
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 aze to
indicate the location of the facility.
. _ . .. ---^rr-^---'�^-�- .. : �--�-- ---_ -
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� � �L1NIT BOUNDARY,
DECK
/ (TYPICAL) :
�
6'-0' > � . p5t-3' COMMON AREA �1NIT BIXINDARY �
�7R+ � � �Q% /� I (TYPICAL) '
'C7/ �
� � i 9'-1�" 10'-10' o is•_q• � 11'-�" 9�'��� .
� (�5 4�
�' � � i°t7MM0 „ ;;� R AQ
N N p �
UN I T � � � �- N "� BED R00)M KITCHEN ` KITCHEN BED ROOM �
s4- I � � � . � � N ; , � 0 � N/F
� . 2._8., � � z._8. � � � ^
c � , y C , DIBIASE
�_ � , � ^CLOSET 5'-5" 5'-3" i
� �
C�V�N � . � , - .
� � y!� BATH ROOv ` } > �.� BATH ROGM � x — x
. � � 9. ... � � � � 9'-10" +
. . vs��_�• \ i . _ HALL z � c ? HAI:. . .
� � � / � CIOSEi ,{y�^ CLOSET a o, � � CLOSET �❑ q'_g•' LOSE� 6'0� � 1 �_ �
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1 � 1 t'-7" it,_7•
5
a� s`2' �
N UNIT 64-2 � � UNIT` 62-2 � ' _- k64�2 � s�2 _ N '
� m i � - Sn �ED ROOM LMNG ROOM '�' LIVING ROOM "� BED ROOM � PROPOSED
� { ^ i 4 EASEMENT
_3,. . 1 j —
� �o � u �L� �o i 3 � �0
' 6'-3" i 6'-J" ^ MMO ">AR , ^
N� pY ! W
BASEMENT 6'-3� F R O N T E N T R A NC E �'�-3� � I 2 � � 1�
►�
. � COMMON AREA f"d
UNIT 64-I UNIT 62 - I /��F i " �
' NORD YK q
DECK i � � • '•.�NALK. ' .
� � Y
FIRST FLOOR �� a
3
m �
L��� � U
N0. E4 & 62 Z � �
NIT BOUNDARY EXISTING BUILDING S ¢ �
o � TYPICAL
9-17" 5'-4' S-4� � 3-5� � ( , 3�-3" � �
- ���-�m� @� M M � , 27,_p,. � 10,_4.� io 5'-5" �i 10,_3„ . � m �
�' BED ROOM ' DINING ROOM� w � HALI. ' w o �
. � KITCHEN KITCHEN � � N . "v ,
� o� Q, . . � b, tO o � � BED ROOM o � � � 2
`O � � m � fD `� BED P,OOM �j r� ,�j U � B E D R O O M a� � 9 � �
o � � ' i� BED ROCDM Q � � m 8'-7"� � i� �' W ' ,
. q'_7�- , SIGN;.
m g_a'. i. - .. , {�
5'-3 � B'-6 `
. BATH ROOM N HALI PqNTRY .i N PANTRY � , � 2 L 4 • ' ,
m
� . BATH ROOM i o - w
� � 4._�. ' . 9'-10" i° � _, , .
BIT. CONC. SIDE WALK � 10
� � . HACL � m �g• HALL � .� I � HA� � 19�-7' � i <7-„ �
� CLOSET � � CLOSET � � � v � .
b . G'nAN17E CURB
, � �• 5� 4-3� CLOSET LOSEE � i , CLOSE CLOSE � ,(,') •
� � �._6.. � �i� a �� A Y � // ^NCH MAR��:
� I ��,.5� s. ...c , o` �.
11'-5" 77'-5" � � �( � g�_�^ � BATH . _....._ . ��
1 -8 1 _6` ` � ° BED R�oM �o �. 1z�`�� o OLL o rtoo^ . . � `� E EV.RIM 50.00 ASSUMED
BED ROOM �^j N N � BED ROJOM u i � g�p RDOM � i � '
. iO LIVING ROOM '^ LIV�NG ROOM " o' DEN � 1O � �� a+ �
� � 3'_3• 3•_p• � ' � �0 -� " � S I TE P L A N
� c CLOSET= ��j CLOSET ';� . 1z�_�• � ::LOSET _
J �
i . a i _ .�__ ' ��� = 20�
^ c ^ . . ~� .. . .. g•..,:-....�� .
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UNIT 64-2
I �11N1T BOUNDAAY THIRD FLOOR UNIT 62-2
UNIT 64-2 SECOND FLOOR �'�'P'cA�� UNIT 62-2 � i
FLOOR PLAN J
�
1 „ = 8' .
' � �
THIS PLAN lS BASED ON THE REFERENCED PLANS, DEEDS { `-- --� , I
f AND THE RESULTS OF A F/ELD SUR�EY AS OF THIS DATE. I
NO CERT/FICAT/ON lS INTENDED AS TO PROPERTY T/TLE � �r I
OR AS TO TNE EX/STENCE OF UNWRITTEN OR UNRECORDED i
EASEMENTS. _ i
' I � /` e� �
p_-i.i 7 ,�D
l HEREBY CERT/FY TH/S PLAN CONFORMS A i TIC ~- C O N D O M I N I U M r, � ° �" - ` '£ �'c`-`�' :
ASSE SORS MAP 14 PARCEL 157 r -�.- -`�
TO THE RULES AND REGULAT/ONS OF THE SITE and FLOOR
I REG/STERS OF DEEDS OF TNE COMMON- THE SITE PLAN OF LAND WAS PREPARED DEED, BOOK 23389 PG.536 � _ . . , , -- J
WEALTH OF MASSACHUSETTS. . !N CONNECTION WITH CONDOMNNIUM i PLAN OF LAND �,� ,�f�
3RD FLOOR 68.5 DOCUMENTS AND lS NOT INTENDED OR � LOCA �ED lN �� ��
I REPRESENTED TO BE A LAND i0R � T �
t PROPERTY LINE SURIiEY. ND iCORNERS gUILD�ING CONSTRUCTION IS WOOD FRAME J A � E M , M A S S . (n F ' ` "`Vr
WERE SET. lT CANNOT BE US��D FOR
2vD =LOOR 59.3 ESTABLlSHING FENCE, HEDGE, (OR ON STONE FOUNDATION. PREPARED-BY -
BUILDING LINES. ,
FOR REGISTRY USE ONLY �� , EASTERN LAND SURVEY ASSO�IATES, INC.
I CER T1FY TNA T THE PROPER TY L' INES SHOWN ARE � CHP,lS TOPHER R. MEL L 0, PL S
� 1ST FLOOR 50.0 THE LINES DIli1DlNG EXlST1NG OWNVERSHIP, AND THE I !HEREBY CERTIFY THAT THIS PLAN
LINES OF S7REETS AND WAYS SHOWN ARE THOSE FU[LY AND ACCURATELY DEPICTS THE AS TOTAL UNIT 62 - � 79� � '
— OF PUBLIC OR PRIVATE STREETS' OR WAYS ALRE�DY TOTAL UNIT 64 - � 104 LOWELL ST. PEABODY, MA. 01960
-- E�rABLISN=D AND NO NEW �lNES> FOR DIIiISION OF ?UI_T LA`'OUT, LOCATION, UNIT NUMBERS, 780 :
cXISTING OWNERSHIP OR FOR NEfW WAYS ARE SHOWN. JI�!='�'SIONS, AND APPROXIMATE AREAS TOTAL UNIT e2 - 2 isso (978) 531 -8121
cEu�A� ^ 4'.� oF ;HE UNITS AND COMMON AREAS. roTn� uNiT s4 - 2 is7o SCALE AS NOTED JANUARI� 24 � 2005
TOTALL COMMON AREA 1230
TOTAL COMBINED AREA 6130 6 2— E�j 4- H I GH LAN D A VE .
FLOOR ELEVATION '
NO SCALE � - 8 �
;,� ::.
' 0 4 8 16 24 32 �: �`
� �- � ��'.:
' CHRISTOPHER R. MELLO PLS CHRISTOPHER R. MELLO P.LS. 1" = 20'
o ,0 20 �o so ao F 1 3 8 3 2
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