100 HIGHLAND AVE - BUILDING INSPECTION (3) No- \-�4 City of Salem Ward _
4
oat 'r�r
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Ap
p
licantto complete/all items in sections:I, It, III, IV,and lX.
L AT(LOCATIONI �6 �� ,S ` '"'� �'r ZOMDISTRICTNG
LOCATION N0' a
OF BETWEEN AND
BUILDING crross alalfT rROSS
LOT n
SUSOPASION LOT_BLOCK SIZE
11. TYPE AND COST OF BUILDING-All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT 0. PROPOSED USE•FOR"DEMOLITION"USE MOST RECENT USE
1 ❑ Now buddng Rank insatl Ndnewwraw
2 ❑ AddM*n le msidenfrl.enmr numbsW new, 12 ❑ One%nwv ISO AmMwanL moaaUSM
ng units atldetl.4 any,inpan D.13) 19 ❑ Chlum,Other relnQus
13 ❑ Two s mos lamely•Enter number 20 ❑ IrldtamW _
3 Aeeremn(See 2 amw) at uMe--
21 ❑ Paftm garage
6 ❑ RepaM reputemem 14 ❑ TWA**mmM,rrquL or dpnrdtprl'• 220 Suaarl moan garage
Elrelrnumbs pr un4a .
S ❑ WneUwg(S mubdarrry msdenSlY,ems rwm0er 23 ❑ HOephL saetMiOrW-
o una in oading in Part O. 13) 15 ❑ Garage 24 &&M Dardr.pmtWgrW
S ❑ MmvV tmWabon) 19 ❑ Carlson 25 ❑ Pupae w ty
7 ❑ Fomdatbn Only 20 ❑ SdwW kb wy.oths educaWft
17 ❑ 0111e1,-Specov 27 ❑ SloanmerearmM
8.OWN E,IiSHIP _28 ❑ Tarou,towers
I�Pmam IUMrviauak Oorpoatwn rwww 29 ❑ Ogw•SpecM
inatwon.nc.l
9 ❑ Publb rFede .Stow w ioiil Wwmmere .
C.COST k,,,,,,,,,,///// (Omit cans! Nwires tlenta m ineu)l-Desrae detail OMPOS d use budds,e.g.tom wn orpeg punt.
j16 bM
6CIG _ ad &M usury budding at msmal.eumantary acrlool.seminary School mN SM
T parbenel eurow llarkll9 g�rge IOr deparbrrrs ee,mnul mice buddellylls ot Widm9
10. cost Cot knprovenlsp -- S at slduepel WAnL d use of eeetn9 Widdin9 m bwV O wrged,enw prbpbMd uaa.
To be nslallsd but not ircl ded
in gal above cost
a. Eucamw
a Pa.riery
c Msh+g.w mndab w 'Cr
d. Oew(ebvos.or-)
11. TOTAL COST OF IMPROVEMEM $
IIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L:demobtion,
complete only Parts J&Mall others skin to IV
E PRINCIPAL TYPE OF FRAME F. PRNCP OF HEATING FUEL G. TYPE OF AGE DISPOSAL L TYPE OF MECNANCAL
30 ❑ Masonry t.01 e g 35 40 Pubkc a IN w company W/pain bs ai
31 ❑ Wind home 36 ❑ 04 41 ❑.Pr"438 Mje tartk etc)
32 Zsb chm sw 37 ❑ EIeC4MJly 44 Yes 45 ❑ No
33 ReeMoroea tonraau 39 IL-TYPE OFF ATER SUPPLY
❑ ❑ �. Lru7/ Wi gwa ayn snaM
34 ❑ O0W-SparOy 39 ❑ Ogle-SpsOV 42 Pmgc a prieau mngsry ,
w ❑ Yes 47 Np
43 0 Prwta Iwaa.cw m1
J.48 N.,,wNS M. DEMOLITION OF STRUCTURES:
49. Tow a are rear or Moor area
Has Approval from Historical Commission been received
a,: oaseo,an B�..._..................... - . for any structure over fifty(50)years? Yes_ No_
50. Total mno area.so.M..........................._......._— -Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51 Entbseo...._.......-.__.._._....._._.-.--.-._-
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. o�t000rs....-.._..——._....--- ---...— Yes No
L RESIDENTML BUILDINGS ONLY
53. FxkeeE-_--- Electric:
Gas:
Full-- Sewer:
54. Number or
oaoaoa,m DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
----- BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No (If yes,please enclose documentation from Hist.Com.)
Conservation Area? Yes_ No (If yes,please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes No_
Is property located in the S.R.A. district? Yes_ No_
Comply with Zoning? Yes_ No,-- (If no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No_ (if yes,submit documentabonld no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yes_ No_
Is Architectural Access Board approval required? Yes_ No_ (If yes,submit documentation) 1
Massachusetts State Contractor License#C S 3 Salem License* 1/n 7--'- l
Home Improvement Contractor * ,/2 y� Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
t
H an extension is necessary,please submit
CONSTRUCTION IS TO BE COMPLETED BY: / 6$ in writing to the Inspector of Buildings.
V. IDENTIFICATION • To be completed by all applicants
Name �./ Meiiv amress•Number.street car,ana me LP Code Tel No.
Owler or
Lessee
2. A714T S��F
Cowapor 4s-r- 1
Pjit r7 Q/�/� us ' 9.. 3
a.Archralm or 1 2$53 9
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his aumorizeo anent ana we agree to conform to all applicable laws of this iunsdiction.
Signature of applicant Address Application date
I
i
'i DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building
use Group
Permit issued 19_ Fire Grading
Building
Permit Fee $ Lira Loading
Certificate of Occupancy $ or ed Occupancy Load
Ap by.
Drain Tile $
Plan Review Fee $
TITLE
NOTES AND Data -(For department use)
PERMIT TO BE MAILED TO:
DATE MAILED:
Constriction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
i
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
�I
SITE OR PLOT PLAN -For Applicant Use
12
I
O N
v
CITY OF SALEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
}. SALEM, MA 01970
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 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 19L S 150A.The debris will be disposed of at: 166 Z, //o1'14te- Grp lrzl ' /per
Location of Facility
.2 6S
lgnature of Permit Applicant ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
/3 �. L 5G /el%-�
Name of Permit Applicant
Firm Name,if any
Zo
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 cIH, S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
7 Department of Industrial Accidents
�,a� _ Ofl16'e0l/pl/OStltl8tl09S
E 600 Washington Street, 71"Floor
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
'A
city �-i` (P� state, i0A zip.O 12 76 phone q tlgZ2 �l
work site ocati n full d ress :
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction Remodel
❑ I am a sole proprietor and have no one working in and capacity. ❑Building Addition
-- -— -- ❑-I-am an employer-providmg workers' compensation-for my employees working on this ob
x r;
_
xx address:,
tir- 4 kErr
am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensattiioon,polices:
company namr.
address: /�/V"ioK///!(� /7•
`L O/S 7G nhone a i1�� 3(�'a^ 31CZ
address._ J/ .. S`,ENX �U - /tc't
(,
city' J_J� �h.�e1 V /•V1Q z" tt + �, >r;
mauran .ua.im..s..s.r:':,i�.-<w +''...++...,_, xN--.� .✓•;r..;.:+.+t '...+wa+Yu.+.
r�sm-+R*^a7rea+w��an
•:1 v ' tnplievkw
Failure to secure coverage a+required under A of MGL 152 caa lead to the imposition of criminal pent ies of a fine up to 51,500.00 and/or L
one years'imprisonment u well as civil n the form ofa STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be to he Oaice of Investigations of the DIA for coverage verification.
/do hereby certify unde nallies of perjury that the information provided above is true and correct
Signature Date (5
Print name Phone p / 6•�6
official use only do not write in this area to be completed by city or town official
city or town: permil/license p
❑Building Department
❑check it immediate response is required ❑Licensing Board
❑Selectmen's Office
contact person: hone p; ❑Health Department
aonrd sryi.!n+n P ❑Other
Information and Instructions
Massachusetts General Laws chapter 152 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
the foregoing engaged in ajoint 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 apartments 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 shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or[&a—Flicensing agencyshall-withhold-the-issuance-or----
renewal 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 with 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.
Applicants
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 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.
3•
City or Towns
Please be sure that the affidavit is complete and printed legibly. 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 regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations 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.
The Department's address;telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Well of IM1098111/M
600 Washington Street,7'"Floor
Boston, Ma. 021It
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406