205 HIGHLAND AVE - BUILDING INSPECTION t
S-MOST-OE fILf D,APPROVED BY T44E
,IJ�SAECJ[?A ,PFfJPR TPA:P.EBMIT B,EWO GRANTED
A, i
CITY OF SA°LEM
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No. .Zc) bC\ 1,3`` p Date /b.17•n3
r d$ Ward
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\°�rMiNrcA' : Zoning District
Is Property Located In Location of QD$ }.�—
the Historic District? Yes_No_ Building hrWAUD Pve.
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: k;r^ te.►c. fef , rear
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name sit 9. 0"=0 d Qo.
Address & Phone /00 4AAtAV1 o RD Q3 Mjk1(7e1 )84R-7►11
Architect's Name 77AY Hwtrw Aacgw j!�awy
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Address & Phone Ica+AkAm 22,44
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Mechanics Name
Address & Phone ( )
What Is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost 42VOrOdo �— City License # Statea a se # CXS 66'3M
27� Home Improvement
t �° Lic. t ignature of Applicantto A�
�Zom SIGNED UNDER THE PENALTY
�Z OF PERJURY
DESCRIPTION OF WORK TO SE DONE
�suwz�,oc, � �u:wf� ��� Ntl s t3rncar�
MAIL PERMIT TO: 10 INDusn 1A(_ );b. Ha roeb, AJA 01IS-1
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Plumb House 10 Industrial Road
Milford, MA 01757
Phone:508-482-1971
Fax: 508-482-9167
PROJECT: Hawthorne Commons LETTER OF TRANSMITTAL
TO: City of Salem No. 00334
Public Property Department DATE: 10/29/03
120 Washington Street REF:
Salem, MA 01970 PHONE: 978-745-9595
ATTN: Thomas St. Pierre FAX: 978-740-9846
WE ARE SENDING: " s SUBMITTED FOR: 'ACTION TAKEN
❑ Shop Drawings ❑ Approval ❑ Approved as Submitted
❑ Letter ❑ Your Use ❑ Approved as Noted
❑ Prints ❑ As Requested ❑ Returned After Loan
❑ Change Order ❑ Review and Comment ❑ Resubmit
❑ Plans ❑ Submit
❑ Samples ❑ Returned
❑ Specifications ❑ Attached ❑ Returned for Corrections
❑ Other: ❑ Separate Cover Via: ❑ Due Dale:
. ..��... ., ., . ym ,.......� ,..-.,.,.. 978-
m
ITEM NO.'iCOPIES DATE.. ;ITEM W,NUMBER zoL .REV.NO DESCRIPTIONS ; � STATUS
1 Corcoran Management Co. Check 376176
1 Permit application for 205 Highland Avenue
Stairwell pressurization
Remarks:
CC: Signed: —
Dave Boucher
Expedition
co CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
% 120 WASHINGTON STREET, 3RD FLOOR -
}, !Qa SALEM, MA 0 1970
ffe TEL. (978)745-9595 EXT. 380
gyp' 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 at: LyNd MAOSFB2 3rA"j%%1
Location of Facility
'� /0.29.0 3
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
/D 1A1b1,'5TR1*L- RA•
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
(formonwr:aLih of nitacLeffi
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Workers' Compensation Insurance Affidavit
1, — Richard K. Anderson, president of Plumb House , Tnr .
.rreaef
wich.a principal place of business at: 10 Industrial Road
Milford, Massachusetts 01757
toensw✓sar)
do hereby'cercify under tht pains and penalties of pe4my, that:
�) I am an employer providing workers' compensation coverate for my employees working on
this lob.
ABG Massachusetts Worker' s GDX014387B ( see attached)
Compensation Self Insured• Group
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor imuran�e Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() lam a homeowner performing all the work myself.
I unoerwne wt a coon of ehe w,e t we be ior.+ar"d o, the OrfKt of Inresrnavont of ehc DIA Ior coraratt+erlRcatien arse Drat raixt ea aewn
�oe erarc v rewrra uncer Seceion 25A of HGL I S 2 can k4t to tot n oofnion of crv+vnat och nskj corx Ent of a fee of ao w41.500;00 XrWor om
rcan' ir.- ( a tru u chi ocnafuu inehe loan of a $TOP WORK ORDER anc a fee of S 100.00 a oaf ata+nt ee.
Signed this , 27th day of October 2093
PO—Lp-ram l -
iccnseeibernittct building Geparcrnent
ucc;Ling Eoaro
Selectmens Office
�,�tth Uepar'rnen:
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