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60 JEFFERSON AVE - BUILDING INSPECTION EI`I' SALE M PUBLIC PROPERTY DEPART1fENT KIMBERLEY DRISCOLL MAYOR 120 WASFfINGrON STREET 0 SALEM,Mi15ACH1:56"11S 01970 f/ ✓ TE11978-745-9595 4 FAX:978-740-9W APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION ' Location Name: Building: Property Address: 60 3-e:�-Cc'ersoTl Avg I .�a��rr� , f`/l4 Property is located in a; Conservation Area Y/N_�_ Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land e Name: IZ"("D Norm �ea� �sEc�#2 'G—cvs't' Address: to 3 1/z �2 Fie c so f}v salevv\ O\c-To Telephone: Cirl S - rj y�( _ S o t5 d 3.0 COMPLETE THIS SECTION FOR WORK IN EXISN NG BUILDINGS ONLY Addition 9Existing Renovation Number of Stories ed Change in Use Demolition Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to - What is the current use of the Building? t'o�me'r �od`P �110(� Material of Building? UJ00d./J j0CK If dwelling, how many units? JA- Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# 05 3 B_l L� HIC Registration# Ff 13 i © 1 q 33 Estimated Cost of Project$ Permit Fee Calculation Permit Fee$ Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned.does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date �1 N O J f y S J. o 0"b S ., 7t O y\ V L g CITY OF SALLM T FIRE DEPARTMENT - FIRE PREVENTION BUREAU Salem, Masssacchuuseettb 01970 PERMIT Date: In accordance with the provisions of Chapter 148, G.L as provided in Section 10, this permit is granted to Irall nama d y.naa.Was or carrw,atim Oraald rml 1 4 ` to conduct demolition operations per Salem Fire Code , State p purposee for ?nassachusetts Fire Prevention Regulations and Which permit Massachusetts State' Building Code. is granted Restrictions: As per Mass. State Codes and City of Salem Ordinances. Clearance fran Salem Historic conmission. at 1,y � :al.. 1--kaa br auVat and oa., w d-cdb. Is auah mam r as to pa•Ida adequate Ideadeemlen of laaatlon) Fee Paid $_aa_as�0 ISWaalan of*111dal o�ha.v.�ln This permit will expire FAO ITIU.I Or (THIS PEBNIIT MUST BE CONSPICUOUSLY POSTED UPON THE PRDUSFS.) aw Form #�9C CITY OF SALEm PUBLIC PROPERTY DEPARTMENT w,OUS,Y CRMC= Wroa 130 WAUGUGU M SMM•Suss.MASACNl'>EM o1910 Consimcdon Debris Disposal Affidavit (requirdd far aU demofidon aad movadm work) In aceo<danea with ft six&edidom of dw St m BuMns Cods,7So CMI;section 111.5 odbr*and dw provisions of UM a AA 9 54 qua t3 pannit si is isamd With dw condition that dw debris raaltini fto this work sbdl be disposed of in a properly Nc®aed waste disposd dteiUty as defined by MCI.a !L1.Suo& Tie debris wiu be transported by: —Z! Dg Services (acme acbrw " The debris wiU be disposed of in: (name of&Wiw) (addno of f3ailiry) sisaaew olpernsit applicant don tshri.r74s CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3Ro FLOOR Qr01� SALEM, MASSACHUSETTS 01970 TELEPHONE: 978-745-9595 EXT. 380 FAX: 978-740-9846 Thomas J. St.Pierre Director of Public Property Zoning Enforcement Officer Section 116.0 Demolition of Structures Structures over fifty (50) tears old must have approval of the Salem Historical Society UTILITY DISCONNECTIONS REQUIRED Authorized Agent Date of Disconnection Water: (see attached requirements) Electrical: Fire: Sewer: Salem Historical Commission: Dig Safe Number: o�00& — 4310 3 10 Pest Control: ***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE PERMIT-CAN BE ISSUED*** Fee for Demolition: $5.00 for application plus$2.00 per 100 square ft.gross area, minimum$15.00 I j/ F LA znaaLiTlt3PIi� far:s :;. �7rranns t ai•� SFPR 29C In accordance with provisions of General Laws of the Commonwealth of Massachusetts and the Salem Fire Code, the following regulation governing the demolition of structures within the City of Salem shall be followed. This regulation is made in the interest of fire prevention, to prevent conditions which are or may become dangerous as a fire hazard, or are otherwise in violation of law. 1. Before a structure can be demolished, the Salem Fire Department Shall conduct a preliminary demolition inspection, to ascertain any conditions which may require a fire watch or other preventive measures , to be taken before , during and/or after said demolition process. 2. A permit to demolish or remove a building or structure shall not be issued until said inspection has. been conducted, and a report of requirements necessary for prevention of fire and life safety hazards shall be obtained by the applicant for the permit. 3. The requirements outlined in the report shall become a part of the restrictions portion of the demolition permit issued by the Building Inspector, for compliance with the Code. 4 . The inspection report shall include, but not necessarily be restricted to the following: A. Welding and cutting permit required. B. Fire watch to be maintained by a professional off-duty firefighter, with such equipment as determined by the head of the Fire Department. Per Order: A Approved by : ' " t Lieut. David J ggl Salem Fire Mar al James F. f nan, Chief Salem Fire Department (8/76) ...� ;�a:'�t1 � ..y Y w r w '" -w .3•.c '• �1.iM -.r.'�".6Tia�.a•Sir,.ufhw* r ._t + 4. - .4 � .a,... ., , ." .. i a1...�._.�y � e�.r:, 1 vY r'..•✓lea .,! . ar { '..c ...' y> �' .]-672q -. a..+r.+e a. i � it •. t x ;�•G Y..Rv:rG'�'TE1T::.�`,LY� fl•i{rl�.F�Y .r •II . r ' 60 CMR: STATE BUILDING CODE COMMISSION SECTION 115.0 CONDITIONS OF PERMLT i I 115.1 COMP Hance with code: Tha permit shall be a license to 'Y proceed with the work and shall not be construed as authority 1p provisions of this to violate, cancel or set aside any of tmodiification or legally code, except as specifically stipulated by s 1 granted variation in accordance with Section 126.0. erm>it: All work shall conform to the I i - 115.2 Compliance with Pwhich stamped or endorsed aPpica ron and oved amendments thereto.the Permit has been issued and any pp Change in site plan: A lot or site shall not be changed, 115.3plan area from that shown on the official Increased or diminished in I �: as specified in Section 113.6. unless a revised =4 site Plan. showing such changes accompanied by the necessary I I —< —7 or applicant shall have been filed and approved- ownerI I Exception: A revised site plan will not ai required if a s change is caused by reason of an official street opening. public improvement. I i street widenin4 or other J Svt- !. t:..K•��'�=�+ SECTION 116.0 DEMOLITION OF STRUCTURES F-+ts 116.1 Service connections: Before s building or structure can all be demolished or removed, the owner or agent shall notify c ssttrUC- utilities having service connections sewara and other connee- E:�y toss, such as: or structure dons. A permit to demolish or remove aned iin9 ':`h^�•t.;• shall not be issued until a release li obtained from the utilities. �I stall n that their respective service cottneca�rstions haveand been re- went, such as: meters and regulators tti ant equip ed in a safe manner. .�•' moved or sealed and p1u99 r .. 116.2 Lot regulation: When a building or structure has been operation has not been demolished or removed and a building �'�'•'.• roved, the vacant lot shall be filled with noa- �,;51:•p projected or app with adjacenti ' organic fill. graded and maintained in conformity accumulation r - grades. The lot shall be maintained area fromwhickL of rubbish and all other unsafe or hararC. p c°ri�shall be r the life or health of the Public: provisions endanger and the made to Prevent the accumulation of wavy or damage n any foundations on the premises of�o�sas hall lbbe property; ecpted I'm accord- neesasary retaining 13. ante with the provisions of Article .. r�r[,� •'•�. SECTION 117.0 MOVED STRUCTURES �I i' ^m•'i 117.1 General: Buildings and structures moved into or within the jurisdiction shall comply with the Provisions of this code. I sni80 II . o CITY OF SALEM9 MASSACHUSETTS DEPARTMENT OF PUBLIC SERVICES 120 WASHINGTON STREET, 4TH FLOOR ,q SALEM, MASSACHUSETTS 01970 09�`111y8 BRUCE D. THIBODEAU, P.E. DIRECTOR OF PUBLIC SERVICES/CITY ENGINEER TEL: 978-745-9595 EXT. 32t FAX: 978-745-0349 WATER & SEWER In accordance with provisions of General Laws of the Commonwealth of Massachusetts and the Salem Water and Sewer Department,the following regulations governing the demolition of structures within the City of Salem shall be followed. This regulation is made in the interest of protecting the water and sewer infrastructure at each domestic &commercial hookup location within the City of Salem as well as to prevent conditions,which may cause danger to public safety, cause water to be lost or loss of city or personal property due to water or sewer loss. 1. Prior to demolition of property, a licensed plumber shall ascertain where all water and sewer lines are located on said property. The plumber shall make a determination of use of such water and sewer lines, not limited to, domestic use, irrigation, fire suppression, or septic systems. After all water and sewer lines have been located, the plumber shall make a written report with diagrams of utility locations found to the Director of Public Services. A request to the Department of Public Services shall be made to terminate water services at the street after such notice of locations have been made but not before item#2 is completed. 2. Prior to demolition a licensed drain-layer, licensed by the City of Salem, shall cut and cap the water and sewer lines at the city main. In the event that water or sewer will immediately be used after demolition for construction purposes, a set of certified plans and drawings by a registered professional engineer must be provided to the Dir. Of Public Services/City Engineer reviewed and approved prior to the obtaining a demolition permit. 3. A demolition permit shall not be issued until items 1 & 2 have been completed and the Department of Public Services has conducted an inspection and signed off on the water and sewer portion of the Building Department prerequisite Utility Disconnections Required form. Approved by: Bruce ff. hiWeiirj�f.- Dir. Of Public Services/City Engineer 11105 �. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KAfaERLEY DRISCOLL MAYOR 120 WASH x•TON STREET*SAiEM,MASSACHUSETtS 01970 TEL 973-745-9595 is FAx 978.740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Narne(Business/Organimtiam4ndividual): Address: l O j_ -4:i7 5TER �T City/State/Zip: 1 i=R C3p p y MR 019( a Phone#:_ 4 7�S - 5 31 - 6, 33 Are on an employer?Check the appropriate box: 1.WI am a employer with 4. ❑ I am a general contractor and I Type of protect(required); employees(full and/or part-time).• have hired the sub-contractors 6. ❑New consnvction 2. I am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. g Demolition working for me in any capacity. workers'comp, insurance, [No workers' co ir1Yr l9r 9• ❑ Building addition comp. ce 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.p Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[]Other COMP.insurance required•] *Any applicant that checks box#1 must also N out the section below showing their waken'compenaatioa policy infmmsttoo. t Homeowmn who submit this affldrvit indicsting they am dotes all work and then hire outside cme nimo must ankh s row rContmcton that check this box must annew so additimmi sheet ahowma the Dame of the ankin cn atRdwis smiles x m•trades and their workm'comp•policy tnforma m lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information Insurance Company Name:_ SP_OreV e, $ A SSOC `RC Policy#or Self-ins.Lic.#: TC3 Expiration Date: 10/15 /Or� Job Site Address:. e c) 7S City/State/Zip: SoAe-vti1 m R C)19.—�o Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire don date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby certify under the pains and penalties of per fury that the information provided above is true and correct Sfignaturce t • Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone# Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees- pursuant to this statute,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 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 not more than three apartments and who resides therein,or the occupant elthe owner of a dwelling house having construction or repair work on such dwelling house dwelling house of another wbc employs persons s al maintenance, " or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. ce MGL chapter 152,§25C(6)also states that"every stater t local licensing u Agencdings iin an the withhold onwealth for any renewal of a license or permit to operate a business or to construct buildings applicant who has not produced acceptable evidence of compliance with the insurance coverage subdivisions"shall Additionally.MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its Political 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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if Of necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) th or Limited Liability Partnerships(LLP)with no employees other than the insurance. Limited Liability Companies carry(LLQ tY members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees.a policy is required. Be advised that this affidavit may be submitted to the DepartAffidavit. t Of Accidents for confirmation of insurance coverage. Also be sure r sign and date the aefldavn The affidavit should be returned to the city or town that the application for the permit or license is being requested,to obtain a workeentrs' of Industrial Accidents. Should you have any questions regarding the law or if you are required should enter their compensation policy.Please call the Department at the number listed below. Self-insured companies self-insurance license number on the iate line. City or Town Officials 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 permitflicense number which will be used as a reference number. In addition,an applicant that must submit multiple permiNlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town):'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new af,&vir must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture- (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank yo u in advance for your 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 Offlce of Invesdpdons 600 Washington street Boston,MA 02111 Tel. #617-727-4900 ext 406 to 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia �1.Uf Z4f2I2Ub 11:3a yttl`J tblb'Jb SEGREVE HAL PAGE 02/02 A c P. CERTIFICATE OF LIABILITY INSURANCE Ha�SR CiH 1io i os FRODucER THIS CERTIFICATE M ISSUED AS A ANATTIKK OF INFORMATN7N Segreve & Hall Inaur.Assoo.Ina HOLYANDCCO CERT4 No IFICATEMGM UPON THE ENDTFFICA OR 305 North Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Andover M9 01810 Phone: 978-975-1300 Fax:978-975-7596 INSURERS AFFORDING COVERAGE EN�Ir INSURED "�^�—� INSURERk ArbA11A PradaaLien Ina. Co.. INSURER B:H & S Tank Cleaning INSURER C'.PeaboodytNA 01460 INSURER D: INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN HISIOD TO THEMRURPL MQAM ABOVE MR THE POLICY PERIOD INDICATED,NOTWRNICH THIS F VSTANDINO ANY REQUIREMENT,TERM MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIESR CONDFMN OF ANY ESCRIOR BED HERO N IS SUWITH J CTTTTO ALL THHE To TERMS,EXC ORTI TIS AND ONO ONS OF TE MA DO ISSUEDSUCHPOLICIES.AGGREGATE LNRS SHOWN MAY NAVE SEEN REDUCED SY PAID CLACda. 7�__ URANDE POLICY NUMBS! 0A DATE LIMITS PACNOCCIIRRENCE a NERAL LUIBLLRY PR IS"fea aamaeneey R j 6 ❑OCCUR RS06XP GA16'one penan) t PERSONAL 6 ADV INJURY 6 GENERAL AGGREGATE 6 MITAPPUES PER: PRODUCTS-COMPpp Acc 6 POLICY j �T LOC - AU'TONO&LE LIAB6JTY ANY AIn•0 I�MBB�II SINGLE LIMIT 61,000,000 ALL OWNED AUT08 A X SCHEDULED AUTO$ 91067400002 03106/06 03/06/07 BOOLLV MJURY a fPen peraan) X M AUTOS X NO BOOBY INJURY 6 (P-mddenD PROPERTY DAMAGE S . tPeraxmenq GARAGE LIASILIn AUTO ONLY.EA ACCIGENT R ANYALMO OTHER THAN EAACC R ALIT ONLY: A00 6 E[CEB9AIMBRELLA LfAMLITY EACH OOCURRENCe 6 OCCUR CLAIMS MADE AGOIYEGATE - S - DEDUCTIBLE a ... 8 RETENTION 9 .. WORKERS COMPENSATION AND 6 EMPLOYERS'LMB4JTY Y LN ANY PROPRIETOMPARTHERIEXECUTNE THI 10/3-5/06 10/15/07 EL EACH ACCIDEM' a5DD000 OFFICERMEMBER EXCLUDED? e Sa9,Na�eaau r E1.DISEASE-PA EMPLOYE 6500DOO PEC E.L DISEASE•POLICY LIMIT L500000 5 app Cp30801380 09/28/06 09/28/07 PROPERTY COV, $25 0 DESCRIPTION OF OPERATIONS I L TIONS I VEKIOLE91 EXCLUSIONS ADDED BY EH EMENv PEOMR PROVISIONS Plowing in Salem, MA CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF"IS ABOVE DBBCRIBED POLICBO LOACORCORp BEFORE THE PXPBIATTON DATE THEREOF,THE 199UMG NSURER WAL ENDEADAYS WRITTEN City of C. lemHill, NOTICE TO THE CERTIFICATE HOLDER NAMED To TTOAIRE Tn 00 BD SHALL Albeit C. Hill, Jr. 120 Washington St. 3rd Floor IMPOSE NO OBLIGATION OR LIABILITY OF ANY KINGRER,ITS AGENTS OR Salem MA 01970 REPRETMNTATMEEB. AUTHOP ED EBENTA xx I. ACORD 28(2001105) trick D HEAI /Jt ORPORA N 1988 it