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162 HIGHLAND AVE - BUILDING INSPECTION . , — en�oF�xr.E�r- - ' ��� O� PLBLIC PROPERTY . DEPART�IE,�1T I:I�OIFJthY D��v-�r 1 �IAYOI I�WALi1M4�7N J�i1F3sT� ' S��y,�oasr�not9�o lta:9'L7ii9S9S� F�1L•97L7ia9bN APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION. DEr10LITION. OR CHA,'�iGE OF USE OR OCCUPANCY. FOR ANY EXISTING STRiJCTURE OR BUILDING . 1.0 SITE INFORINATION � � LocatlonNams: � tz e5�ca NG Buildtng: �s ,�' property Addreas: f 6c H�9h L�in+� q�� '�R�c+ /�t.schec� .�e ���le.� � MA property Is bcated in a; Coneavatlon Area YM �l Historle Ofsbict YM�L 4.0 OWNERSHIP INFORMATION Z.1 Ownw of Land � ' Nams: �;:� � c e a Address: ib d /�/J/1/ci n d /}v� S�-i e m � Telephonr. y7� %79- 7/ ��- 3.0 COMPLETE THIS 3ECTION FOR WORK IN E7GSIli�d BUILDINGS ONLY Addition Exiating Renovation Number of Stories Renovated Change in Use New OemoliUon Existfng Approximats year of � Area per floor (s� Renovated construction or renavation of exiating building New FIriP/Descriptian of Proposed Work: � � Ne� CoNs+2.�c+�o� z4 '�c 30� (a�reA�� — Mail Permit to: �C-,�f oT7 — -- - - What is the curre nt use of the Buildingl Mate�al of BuildinqT ' ""'^ f If dwelling. how many units? , . . WiU ths Building Conform to Law9 �_�___— ��gt°s? /�kml� p,rcAitecYs Nams Address and Phons ( ) Mechank's Name ����� v ����T� — Address and Phone`� � �.9�..��N.v�'•P l.� ,N1.9- �/9�� Construction Supervisors License+� C��24�i3 HIC Regiatratfon� �'�7 243 Estimated Coaty/ f�rojed S �n�.� PermM Fe�Calcularion Pertnit Fee i—��� Estlmated Cost X S7/S100a Reaidential Estlmated Coat X S11lS1000 Commerclal An Addkbnal S5•00 is added as an AdminfatraWe charge. Make sure that all fields are propery and tegibly written W avoid delaya in procesaing. The underslyned does hereby apply fa a Buildiny Pertnk to build to the above stated X�� _ speciflcadons. Signed undx penalty of perJury Date y-l3-o�_ � � � ,� � 3 e � � y ' � � � o � - :. � V as � � � J � :; �� ° ,,\ V > 3 c- e� � \v � o g x y ��1 � y 3, w a � 4 � _- - E- - - ..�- - o�.- E--- � — — — -- _ : � -. 4 . ���- o�' , i- . "�^�oY�'ui��ng`���.o � . � Constructlon Su g at��an'��O ar�s° . � . ����..., Pervfaor Licanse �.�� LicenBe: CS � 82443 . � Expirallon:� 1/4/2010 Trle 7 *- .,..`. `p RBaWcNon: 00 415q - TOp DV PR 07Z PO BOX ggp ' II L YN �--�. NFIELD.MA 01940 � � IC . . . Cammissio-� f \ •��. �IIL7/t6lU</P_Il�l� } T�F� � Boardo(Quildin °�� �fia°vr��i.�elY6 � �� � r' HOME IMP s R�Kulations anA Sta���ar�s �; ROVEMENTCONTRqCTOR Regfstration: 737243 Expirdtion: 10/21/2008 TYPe: r��D V.PROTZ TODp y pROTZ 3 RI(�IcAF:L`�;9•J L1'NNFIELD.MA 01940 ��i�� ' - � ne��tYAdministrator �+ I4 1 � CTTY OF SALEM PUBLIC PROPRERTY � DEPARTMENT :,�.��u.�sr wcq:.xi �I.�r��a (2t rwflr.w'Ya�+S711QT�SAILY,NA8AC7e:IF'IYs0l9TJ ' 'CaL 97�.1a3+K93 �F.�x:97wl�GwN6 Wwken' Compea�ado� Iosurante Attidwit: 8uildenlContncton/Eleetridans/Plumbe» Anntleant Information Plea� Print LegiAlv Vame�Iw�n;:,rcxa,m:alloN�rnuv,anl►: � ! _rr��` `/ �} 2�7'T7 AJdress• � o � o q y 1 R X �Q���tiG�i�� /1..� / � IG CitylSt3tc/Zip: " I'hone H: 7 - 2 Are yoo aa eapMrv'!Ctiacl[eM aPpropriau!o� 'ryw orP.nJ��(►.9W.�.a). I.� I;ua a cmybyar wi�Y 4. Q I am a Ycrosral taotnetat oad 1 �mpl.iycex(full uLYur p;uo-tinu).• have hin.-J che,uA-cwunctas S' ❑ P'ew conrtruetim 3 1 yn a,wk propricca or puutu. lined oe tAe attaehed shcet = 7. ❑ Remodelias ship and have m omptoywr 7'hes�wbconaaemrs haw tl. ❑Demulitioo wMcin; �'or me in rny capacicy. woricen' wmµ inauronae. (He warkcn'ewnp. inwranc� 3. 0 W�an a eo�poradan unJ its 9' � �"�•rdd�uaa roquired] ot7icen hsve cxciciaal rheir lO.Q ElxtriCal repain ot additions _ 3.O I am a hameownc Join�all work riy6t of exemption pu MGL I 1.0 Plumbin�rcpain or uJditiwu myxlf.[I�o workcrs'wmp. e. !32.�!(4).and wa havc rw 12.Q lGwf tnpain insunnce rcquitrd.J � �mpbyees.(l�o woticea' 13.0 OIGm comp iawran�z rcqu'ved.] . .,.n>.pp4�a.r ier clwcrs uo.�� m.n alw eu a.u.+«eae IKaw.eo.la�ir'v wino•ar�wW+u�vdiry�ne,r.�ius ' I i.ru�.An r�a��Owi��efllAwu i�disaiuK tlwy ao Juiq YI wA a�tl 4�E4e wddr emroosn saw.udn4 s n�w ilRJ�vil inJiarin�aw�. �(',wurxtw+ihr�ks!Mb ba muq atixlrl r addiUmd+Awl.Mori�y We naor of��aM�Yeir wuAaf cv�0.PAKY Ml6rma�fa�. /unr un euipfoytr fhat!r provldln,q worbri'compenmdoa lruaianer joi iny tmp/oytas Bilow Ir rhe puNay unJ/ob�i# iy/�rar�rlvla � Incwancr Company Vame: _- _ - - Policy M ur Salf-iN. LiC. p: _ .. _ F,apirraon Date: Job Site AdJrow: Ci�pSWwZ,p: vacA a.oyy ol�M warken•wmpenaatloa q�11ey dac)ar�tlos pak�(showinR the pu0cy number and u:plratluo d�te} I�ai luru w x:cwe co�erree ss«quiral unJcr Sec�ion 23A ul'�IGL c. I 32 ean lead to�he imposieion of eriminal penaltid of a ti n.up c��S I.SAO.(M�nJ/ar ona-yeu irnprixmmcnt,a�well us�ivi1 pcmltiu in�he form of a STUP WORK OROER arn!a fint e(up m 3�30.00 a Jay a�uia� ihe v�olarnr. Ik advi.�cd Mut a wpy uf this 5�atcuunt muy be 1'urwarJud to ihn UQice of (il\'�ph'�'JltOlb UI lI1C DIA COf 11}'iu(]CCC CpKl:I�L' 1'CCIF)�dIlU11. � /Ju hereb���.di�y unJti�hr puina und/mrtu/Ilrs ujperfury thw d�r ie�orwW/ow OroriJaJ ubow is uri uuJ conret E �i•�,:,r��r•• _.11�l� �c�� I)�rc• (�—/2 Y�� r�,l:��: ��'l z2 3 7q�3 �)/Jlcid�x up/�c /ao war wr/i�/a iAlr arre.JY b/ClIMvIlJ!✓�I C/q nr Mww o/Jli•!�L ' Ciry or fnwn: _ PermiNlJernse Y I��u1nK .\whurity (eird� onc): — -- - . t. Il���rJ uf Ile�lth 2. BuiWin� Deparhne�rt J. Ciqlfoen Clerk J. Electric�l lusp.ctor S. Plum6in� Inspeewr G. O�hrr C„nl�.l Pc�tou: _ 1'honc p: uchons n Instr . Informat ion a d �tass:+.hu;atu Gcncral Laws chapter 1 S2 nquitrs all employ���xivice u anoi�un�du any�convact o[hire. tLcwaiu co�his�:uw�.����s defined a'...evaY P° oapress�x impliod.ural or wTitted" nsoeiaoo�.aorPontioa ar aha k�pl enti�Y.ar auy tvro a mo� .au rr�lbYn is deR°°d as"�ind�idu�4 P�ea�+h�Y. lo a.or rhs e �����tbe lepl rryreunuuva of a 1eee:ua!emV Y .�i�he fuce�o�n�en�a�ped ia a joiet aae�p►ia�. Ho�rcver th� �aweiarion or o�har le`al eaeitY.�P�OY�t���Y� e receivet or ttuues of ys iudiviAud.Pum��+V• ted who residet tAetei4 er the aocu�of dr hours h�vi oot�ooce�e tlrae ap�rm�a� owrot of h�����bYs P��m ifo s•^•••••^•�e,���oa or repait work oo such dweUia�Roua �IweUi� �Kep smll aa bepmt of we�m�pluy�be deamed w br yn employa.• ur on the�nd�ar build(n$appuetenart �iGL chapw t 52.4�(6)�O��.•„,fry stW w leeal lke�t ip�+�wit�YoY tY�furuee or b o nN a Msl�as or b eoWrud bdWln=s h tM commo�wedtt fir ur n�►d of a Iteew or p�rmtt W �ppVe��t wM W Mt yrud�e�d�ceeptabM wid�aca ot eo�Ptluw wtti t4lssun�d eover�s rcqutrad.' �Jditwmlly.MGI.ehapn t 32.$23Cf71+W�+'Naid�er the conunaawealth oor mY o[ia poliucal wbdividom�Aall �� e����y�a�f'puWic worlc undl aaept�bk evidance oFcompliaoce wit6 t6e inaurance mar inw my awhacity." requirsmena of�his cbapur haw been preaenud ro tbe eona'aeanf �pptleasM Ple�ae fill out �Ae aakan' canpensaaon aASdavit compkceb.bY�heelcins�he boxd chu apply w yaur situatioa sad,it neceaary�a'PP�Y��s)name(s��a)�P�m emnber(s)alon`witA theic certi8cate(�)of innu�nce. Limuod Liability Compaaid(LLG�or Limtred Liability ParmenhiP�lu-P)wit6 no empbYw other rhan the membas or Patloen.�+°n°����O e�'MO��'���0°����. [f an LLC or LLP doas hsve employeet.a poliey is roquiied. Be advised dut thu sttidavit may be submit[ed to the Depum+ ent of [ndustri�l Accidents for contlrnution oP insursnee�°v�a Abo b��un to yip aad dsite the Lffldavlt TM aft5davi[should be rctumed w dro eity w rown that t6e apptication for the penait or lic.enss is bein� reques[a4 sW el�e Depacootent of ro leWuYtciul As.:iJenn. S6ould you have any questioo�reQar�n�the low or iPyou ara required co obwin u worken cuiuperuuiop Po�Y.V�eall�ha Dep�ent u�he nuwbet liarcd below. Self-inared companies a6ould eater their .elf-insuraoee license number on the line. C(ty or?ow�Offlclsb ' Ptca�e 6c uue �hac ehe affidnvit ia complete and printed IcQibly. Tde Depsranant har p�ovided n rpuce'rt the botWm. of ehe u'ficL�vie far you a fiA ou�in the event du Oftiee of Investiyacions has w conwct you reQnrdin�the aDp��� 1'lea� be sure ro till ia ihe p�cmitllicense nwn6er which will be a+ed aa a rcference numbar. In addidun.an app ih:u mu►t.ubmie multipk permir/Iicense appluadons in any�iven year.need only submit one affidovit indieacin�curteat policy information lif necessary)and u^dar"lob Site Addrc�s"the�pp4�ant ehould write"uU luca[ionr in__(ci�Y ur rown)."A wVY of tM uftid�vit�hat har bem ofToiaUy etampeJ or muked by �he ciry or town may be pro�idcd w che �pplic:uit as prooPrhat a valid affi�levit u on file fw future peemiu or licensas. A new afl'3dsvit mwt be fllled au ach yw, �y�►ure a hwne uwner or ciuun is obuinins a licenye or pennit not related to •ray busiuess or commercial venturo i i.e. a Jo�{licen+e or rermit w bum leav°a eta.)u�d p�w°�YOT required to complere this�ffidaviti I'hc �)�'tix ot Inva,tigatiuns would li;ca w th�nk you in ,Jv;utce Cor yuut.00pen�iun anJ should yuu hrve any yuucions. p:c:+ac du nut heticate eo giv¢ us •r c11L Thc D.partmrn�'s aJdrcas. eelephone anJ fu numbK The Commonwealth of Massachusetts peparmoeot of Iudusuial Accidentt O!�et I�wsdpdo�t 60o w.��sa�« Bosoon, MA 02l t� Tel. p 617-727-4900 ext 406 ot 1-877-MASSAFE Fa�c N 617-727-7749 2,�„�� ;�,e-os www.mase.gov/dia C1TY OF SALEbt PUBI.IC PROPRERTY DF.PAx�rrr •.VS\I{T' YIa`/L � ]LN�\ ��'�AY/.Vi:�f 7�T��i1��A`r1��Y �L111 i��� �:�'1�'���t.��J�y , r- -� cun:c,rueaa. uee�i. ubpo.st a►masvit � (rayuiroJ aor�II dano�idoa aoa e�awvati�«octi) , (n�ocon(u�cs with tlfr tlx�edida�oldM Stats Suildie�Cod�7S0 Cl�l�soctioa 111.! ! pebris��ud df�ptovisiau of 1�tGL e�t0�S Sli 9uildin{l�w+niR � _ u ia�ad�wi�td eoad[do�fiet tbt debria rewldnf Qos �his wat yAail br diaposod of in s ptopaly liean�ad w�w diaposol f�dltty as d�fMad bq�lB.e <<<. s isow. rn.e�s w;u b. �o�ua by: -- 11be+h��� C I i�m...r noW� 'I � rne:k.-b�, w�u b�t a►.pOsea �rin : E` �i _ e�vt . �'�RNSF'� II j �e.m��i ra.�hq) — �..w:rs,u o�'Y�.:I.�y) Y , . �� / �/-�3-�a � ,.;...tw:.:r,a:rn�.:a.w i4 � �-�•.I�W�.Y� :�i�/'ih��Au'0/—'�4 /.dwy. 11�30�900/ 9'.5�:'_�8 Alvl � � f�l O f*I � ,� X --I Z7 fTl .7 O v� -� o OZn �� . � n � N < m m c) r� D -n � O �� Dm � N � �� frl � � m � n c� • � m � � � � .. 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