15 LARCHMONT RD - BUILDING INSPECTION � /f ���'
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�LS Building SrtA•Y�k�c'�UCt--_ , - .., . ..,�iJr Yards Pruci�l�N,':uut� Rrar 1':uT Pi�n�
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� 1.6 1�'uter Supply: i11.G L c i0. §S1i IJ Fluod Zone Informa[iun: I.S Sewage Dispusri ti��sirm:
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' SECTlON ?: PROPERTYOVYtiERSHIP�
— �
� ? I ONner�ufRecord• � �1 .�i ! �
E�c.<h.s � � �N�'Ji _ . /.� �� rv'-�vrJa>-r! I�oL J�-./B�.- �
� .\.ur i I'nnU Addreu litt Str�icr
57FS �_�8S_��
Itiign:l:�rc �TdCphunC _ --�-�� � I
SECTION 3: DF:SCRIPTION OF PROPOSED 1VORKz Icheck :III IIIIII :I��IIV) i
New C�,n�irueti��n ❑ Esisting Bwlding O O��rr�r-Ocrupird � Rep:ur�Ul ❑ Al;er:m��ni,�O� �
Demo;nwn O i .4�'cr�„riy H(Jg. ''�] �mbtr u��Inus � iJihcr ❑ i;prcii)-. --_ �
—��---�� _�
. � l�riel Descripuun uf Prupused Wnrk` /�Piry /o�. X /�. __ eu_dc�� i1�- G/i-l�--______ �
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' ,�-�_tr.Ser/ �-S S�-on� ��,7�, ✓'bi � `�' /cu.r,� Y'Op�"��
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� � [,ummed Cu,�ti: �
ii�,❑ ---- Officiai l'se Only
� �I.�h�v ,md �iaien,ds� __
I I t3uilJing 5 /3 6B0 j L �wlding Permit Fre: $ �Indirate h���. Icc �. Jcici m�nr��J
� ❑ St�nJard Ci�yll�nun :\ppGr�uun Fte
� '. F7ecincal 5 I
' .. � ❑ ��rtal Prn�ect C���i� Il�tm GI r mulnplier ___ � ___ ___
3 Plumhin� 'S i �. l)�her f�ee�: 5
, 1 Slrihamcal ilil';\CI ) � 1_i.1: _ .- _-__ _ .___ .
�� $ �1Rh.inir.il I I�irC ' - �_ ___. _ __
� C�� � irc.,i��ni /
� -�„i,il :111 Fee.� j�---
;__��- � � —� l�hecAN�i��S l�h�.l. .\muunf� �i�_[�(�d.h \in��unl
. b �ulvl {�fujcct �_�»t i ) ' ❑ P.uJ in F�.ill ❑ Oul.l.in�im_13.iLinir Uut___. __. . ._
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� _ tiF,CIION 5: ('l)NS'I'RUC'f10� Sb:H�'ll'F:S ---- -- - �
� �.1 I.iccnxed Cunstrw�tiun Suprnisor iCSIJ � ,.
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P � H:.i.1.n1iSlU:iuulw„n _--'_—___ '—_—'_�
i.' KeKislcrcd Ilumr Impru��cmrnt Cuntr�ctor IIIICI �
IIIC (��nnp.�m .Vanir�rt tIIC Rceulr�nt N�nic Rcgi.lr�uuu \wuh:r_...._� __ I
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SECTION 6: WORKERS' COM1IPENSATION INSl�R:1NCE :�FFIDAVIT lM11.G.L. c. I52. § ?SCIM1�I
Wurkers C��mpensatiun Insurance al'(idavii mu�t be cumpleied and wbmiiled ��ith �hu applii:nwn. F:ulurc tn pru�iJe .
thia alfid�vrt will result in �he drnial uf ihe ISsuanre�d thz bwlJing permit. �
Signed A�fiJavit Attached? Yts ...._.... ❑ No .-.. .. .. ❑ . .
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i �' -----.- . as Owner��f the whjrw pruperty hcrcby � I . .
Iauth��ncr . tu �ct un my hahalf. in :ill m.itten �
re!�tive tu w�.nk authnrized by this bwlding parmi� :ipplicwiun. . '
i �
--- ------------ i
5ienatwr uf Owncr Da�r ---�
SECTION 7A: UWNER� OR AUTHORIZED AGENT DECL:�R:�"CION _�
1. ���h ,3 � �. c/�Ji-1.�n , as Oaner ur :lwhurized Agent herehy Jaclare
th�t the�taremants and infiumauun un the fureguinp � pliru[iun are true and accurate, tu the brst uf my knu��Irdge .uid
I nrn:,ir. ,/� `
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Prinl V�mc ��_!C �//,4/iW VI.(�/� �!�_��C� "--_
Signuwrc ui Owr�rr or>ulhuntcJ :lgcnl ���� i .
i tiiened under iNc ami and enalucs ul r�u i �
NOTES: {
I. :\n Owner ���hu ��b�ains u budding permi� io du h�Jhar uwn ����rk.ur:m����ner ��h�� hire� :�n unrcgi,tric� u�mr,�. i��r I
(nut regi.+�ered in ihe H�,me Impru�ement C�mir,ictnr 1HfCl Pn��rami. wi�l ��ut h���e arrc., t�� ma ,uhitrau��n j . .
program ��r guaran�y f'unJ unJrr M.G.L. r. 11'A. (>ther imp�vtani inl��rmauun �m �he !ii(� Pn�iram .inJ � I
C�matruen�rn Supervuur Liremmg 1(�5l_i c.in he hmnd in '80('\IR Regulau��ns I IORG .mJ I�IU K�. rc.pecn�cl�� �
�
' W'hen wh,iantial ����rA u planned. pni��Je the inli�rmaw�n hcl��w� ' . �
� T���al tl����rs :ue��Sy. fi.i uneluding �ar�ge. Iini,heJ h�,emanU,�tti... �erA, ��r p��r:h� •
. � (1ru,. livinedreaiSy. Ft.l - H:ibiWbltrnum �uun� � ---------- - .
� Vwnber ��f hrrpla.rs__ Vumher ��f hr�n���in. . .
— _.. _-__ __- . . __ ....
�� Vumhe� ,�I h.uhin�nno _—. Vumhrr ��t h.��llib,iih. ..__- _ . _ .
� �\��C ��� Ile.uine ���ICm ___._._._"_'__'_-_ VuinhCfu� ��Cil.�i �l��i.hc� _ . ._� � .. . .
� I �����r ��l .����lims .�,lcm_-.- IinJ��,rJ ___-_..___. . Up:n _
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� ?. ��I'��i;d Prn�tci tiyu.ire P��„i.ige" m,n br .ub.uw�rd t��r ..�f��i.J Prn�cr� C'��.i.. �
. { .r ��� �
� CITY OF SALLM
y,..' -�', .
� . r� ,. PUBLIC PRc�PRERTY
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` ' �" DEP:�lt'I"�tENT
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II I- '�'9-'�;-��;��� � I��Y: 'i'N.'i:-'i.9J�, �
Construction Uebris Disposal .�►ftidavit
�fl'l�UI1�Cl� IUf :III lIl'i1WIlIIU11 anJ r�nu��atiun �vork) .
In accurd�ncc ��itli th� sixdi �Jition oFthc Statc BuilJing CoJe, 7S0 Ch1R scctiun I I L�
Dcbris, an�l the pro� isiuns uf'�1GL c �0, S 54;
6uilding Permit i� is issucd wi[h the conditiun that dio dcbris resullin� front
this ��ork sh:ill be Jisposed of in a pruperly licenscd wa,te ilisposal facility �s detined by MGL c
l I l, S ISOA.
Thc debris will bc h�uisportcd by: - `
/J�4S/C, /�'/w�'/c.�SR_�l�
InomcoFhaukr) U . . -
l he �ebris wili bc disposed of'in :
_ /�/�� _��t�,�srQ f2L_�
(name ul lacilit � .
i��' / /�� &��i /"�.�
��udJresn u��lacilitvl . .
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i
� �--�IC.�AI P� /A. /!4/1.Gl�'Z.��//'1 � I
+ign�lurc o(p:nnit applicant
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CITY OF S.�1I.El�f
', PUBLIC PROPERTY
DEPAItTMF1vT
�[t�OE�IYY MW:O�L .
Vwro� 130 WI►va�.TaM SrBiT�Su��4wiu0a'saT1s019T0
" � 7tn:9?LNL9S9S� F.ut:97L7d49M� �
HOMEOVWER LICENSE EXE��IPTION
pleas�Prt�t
Date 7 d�
Jobi,ocation i.r �a.�c�L�i-r�o�.,�' � c���Pi� �`—
Home ONm�Address 3 G,^c�•m`� S6/ s `�`- �� S�
Home Owna Telaphone ?�
Presaat Miilin�Add�esr / :L�� o Yr orl_ �., c�_ ,�
The curreni exemption of"Homeowners"wa� exteoded to include owac-occupied
dwelling�of two Unit�or le� and w atlow such homeownen w mgage aa individual for
hire who.doa not posaess s lica�s0.Prcvided that the ownar acts as supecvisot.
DEFINITION OF HOMEOWNER
Penon(i) who own�a parcel of land on which hdshe reaida or intend� W reaida, on
whic6 there is, or is intended to be, a one or two family dwalling. attac6ed or detached .
suucturp accessory tc such use and/or farm structures. A penon who constructs moro
than ona home in a two yesr period shaU aot be coosiderad a homeowner. Such
"homeownd'shall submit w tha Huildin;O�cial,on a fo� acceptable to the Building
Official, that hdshe be responsible for all such wodc performed under the Building
Permit
The undmigned "homeownd' as+uma responsibiGty for compliance with the State
Buildin�Code and other applicable by-iawn and rogulations.
'I'he undmignod "homeowne�'certifia thu hdshe undentands the Ciry of Salem
Building Departmrnt minimum inspection procedura and requiremrnq and that hdshe
wiU comply with said procedura and ra{uiremrnt�.
✓ �
HOVIEOWYERS SIGYAl'L'RE acr,c�' �rk-r�
�J �
APPROVAL OF BUILDCYG CISPECTOR � L
See otha side for state code
� �
���� CITY OF SALEM
� �t��, ') PUBLIC PROPRERTY
,G;,��� DEPARTNIENT
...�I!li i+.i I�1' ;�NI�� ���� .
\I.\1,�H I '� \��\�i ii`:��,:��\l;111 I' I • l.V i �I. \IA��.0 !1; �i� I :� ..1'7'�
��}.�: v-S.-�;.�i;��; � P��: v'8--�:��S�n
��'urkers' Compensrtiun lnsurance :V7ida�it: [3uilders/Contr•rctors/ElectricianslPlumbers
� > >liiant Informrtion Please Print Leaibiv
��:1117� 1 liusin<.. l lr�Jnvanun.hiJn iJu.iU: E/('�`K Y`0� � ���i N/9 i r'I
\�lilr��,: /5 G��v-c��-.f�'savi,� � `�
C'ity. St:uerZip: c5=�e�-._ ��` Phune �: �i 7S' 7�i y r �`v`6 1
.\re �ou �n emplo)'cr7 Check the rpprupriate bux: �C�'pr of project(reyuired):
, I.❑ I ain a �mpluqer with �. ❑ I :��» � g�ncr�l contr�ctor anJ 1 � � V�w consw�tiun
em Iu �res lfull anS�ur art-tinu).• I7:I�Y I11R`iI[I1C Yull-COfIlf7CI0l5
� y P Iism�on the attached sheet. � �� ❑ Rcmudeling
?.❑ I am a >ule propricmr ur partne�-
' ,hip and hav� no employees �fhese sub-coutracturs h�ve . 3. ❑ Demulitiun .
working ti�r me in any capaciry. wvrken' cump. insurance. y. ��3uilding additiun
Vu workers' cum insurance 5. ❑ We ace :�curpuratiun and its
' �. p� l0.❑ Electrical repairs or additions
,,_,{reyuircd.� oftieers have exercixd their
3.IYJ I am a homeowner doing all wurk right uf exemption per MGL � ��0 P�umbing repairs ur additions
myseif. [No workers' cump. c. 152. ,��'I(4), and we h�ve no I2..� Roof repairs
insurance reyuired.j t employees. [No workers' �} � pther
, eomp. insurance royuired.�
�,qi�y,�pplieant ihat checks bux kl muat alw till oul lhe secliun below showing their workers'cumpensatiun pulicy infurma[iun. �
r Ilumeowners whu submit this uffidavit indicating they�rc duing all work and then hirc uWside contracrors mu>t mbmrt a new a�davit inJicating such.
�('uNr.�etnn�hat check this hnx must ultached an ndJilianal sheet shuwing Ihe name ol lhe s'ub-coNracrors and their wurkers'cump.pulicy informa�ion.
/um un emp/oyrr thut is proviJing rvorkers'coiuprnsution insurunce fai my empinyees. Below is the po(ic•y unJ job si(e
iit/�onuufian.
Insurance Company N�mc:. .
Policy X ur Self-ins. Lic. #: Espiratiun Date:
CiryiState/Zip:
I Job Sitc Aihlrcss .
. . , iratlon date .
. . t' n �olic deilaration a e (showin the policy number and exp )
�ttr�h •r copy of the workers' compensa w p y p K B
Failure m .eeurc co��erage as reyuired under Sectiun ZSA uf bIGL c. 152 ran Iead tu the imposition uf criminal penalties of a
�1nc up iu S�,i0U.00 an�L'ur une-yc�r imprisomnent, as �vell ;is civil penalties in the tiirm of a STOP WORK ORDFR and a tine
��f up ai S_'�O.OU a.lay :igainst the viul;�tor. Be :�Jvised �hat a c��py uf'this slatentent m�y be ti�nv�rdrd to �he Office uf
In�r,ri_:ui�m;uf ih� I)I:\ ti�r inwrance coc�rage �'erili�:uion. � .
/Ju herrh}' �'�'rti/1' undrr!hr puins unJ pen�d(ii�c o%pe`jurp d�u�the injirrniurion yru��idrJ ahuve rs true unJ correct �
� �X�Q.r� I \ Yi"/ I�'it• �/l�o / P
�i_ii:itiirc. o� /.tAiLM VLt���
�
II �l Z� F' 7 �� �/ — �f�J � / �/ 7�l l`�77 — �l�15J�7
IJ(/iriu!usr ruilp. Da iwt �vri�r ia rhis areu, �o br conrp(a�ted ny���rry�,.r�,��•�� �,�����r„t .
(�ilc ur �I�u��n: . .------ ----- .--- -- 1'crmitil.iccnsc #_-_ —
I�+uing .�u�hurity' I�ircic une):
I. Buard uf Health Z. Buildin� Department ). Cih'iTo.rn Clerk J. F:Iectrical Inspector 5. Plumbing fnspector .
6. Olher --- —�- � .
Cuntact Prrson:-----------. ------- Phone tt: ----
Information and Instructions
\I:u>:irhusens (irnrr:�l L;nc. rh;ip�cr 1�' rcywrcs ail empluyers �u pru�ide workrrs' a�inpcn;alion liir �hrir entployces.
Punu,in� to �his ,t:uutr. an �•�nplqrre is �Irlir.�J ,�s "_.e�rry� per.on in the :rn�iec ��f:mu�her un�lrr any ronlr.ii� o�hire, �
r���rc.s �rt im��lirJ. ��ral or ��ritten..'
.\n rinplu�'rr is .IrtinrJ :u "un inJi�iiluul. p;utntr:hip, as,oiiati�m. e�irpuration ur�nl�er Ir�ul rntily'. �rr an� nvo or.niurc - .
����ihr forre�,in4�n_agcd in a i��int rmcrpri,e. an� IIIiIUiII17K fI1C IC',�'�I fC�fCSCilf:llRCS oYa Jcrra;ed rmpluyrr. or�hz
rreai�rr or trustec UI :IO Illill\'11It1:lI. �:II'llll'[�Ili�. :115Jp:IlIU11 Uf UfllCf IC_L'JI entity. rmplo}ing employres. I lua'ever tht
� n��ncr �il a.Iwelling housc ha�ing not mort ih�n thrre apartmcnts and �rhu resiJes thrrcin. or �he occup�nt of'the
�I��:Ilin_ h��u;r of,in�,ihrr ���hu rmpluy, penuns tu .lo m�intrn�nrr. con,iructiun ��r rcpair ���.�rk un .uch �welling huuse
��r „n ihe cnmm�: ��r buiWing appurtrnant �h�rrto sh;�ll not heraust �f such rmplo�mont be �rrmeJ io be �n rmpluyer." 4
.\1(IL ch:ipter I??. �_'>CI6) :il,o .;t�[r� di�t "c��ery stute ur locrl licensing aqency sh�ll withhuld the issu•rnce or
r.nc���al uf� licrnse or permit tu uperate u business or to cuns[ruct builJings in the commonwe•rlth fur �ny
applicant �rho has not pruduced acceptable .��idence of compliance with �he insur�nce cu��rrage reyuired."
.��IiIlIWI1:lIIY. �IGL eh;ipter I S?, j?5C'1%1 �r,�tcs "\`cithcr the cumnwnwealth nur ;my oF its pulitical .ubdivisiuns shall �
� rn�rr imu �ny contr:rct for dte perti�rmanca of public ���ork until acceptablt eciJenct otcumpli�nce with the inwrance
r�yuircments uf this rhapter have been presented W the contracting �mhuriry." .
:�pplicanls - .
Please lill uut the workers' cumpensation aftiJuvit completely, by checking the�boxes that apply to yuur situation and, if
ncce,sary, supply sub-cuntr�etor(s) name(s), address(es) and phone number(s) alung with their certiticate(s) uf
' insurance. Limitrd Liability Cumpanies ILLC) ur Limited Liability Partnerships(LLP) with no employees uther than the
m�mbers or partners, are not reyuired to carry workers' cumpensation insurance. If an LLC ur LLP does have
c�nployees,a policy is reyuired. [3e �dviszd that this�ftidavit may be submitted to the Depanment of Industrial
;�cci�ents for contirmation of insurance cuverage. Also be sure to sign •rnd drte the •rffidaviL The aftidavit should
be returned to the ciry or town th�t the �pplication for the permit or license is being reyuzsted, not the Department of
Industrial Accidents. Should you have �ny yuestions «garding the law or if you are reyuired to ubtain a workers'
compensation policy, please call the Department ut the nwnber listed below: Self-insured companies should enter their
sclf-insurance license number on the appropriate line. �
City ur Town Officials �
�� � Ple:�se be sure that the affidavit is complete and printed legibly. The Departnent has provided a space at!he bottom �
of'the uf'tidavit for yuu to till out in the e��ent die Office uFlm•estigations has to contact yuu regarding the applicant.
Pleasa be sure to till in the permiUlicense number which will be used�as a reference number. In aJdition,an applicant "
d�at must submit multiple perniivlicense applications in any givan year, need only submit one aftidavit inJicating curzen[
pulicy intbrtnation �i[necessary) and unJer"Job Sire Address'tha applicant shuuld write "all locations in (city or
tuwn�." A cupy of the af�tiJavit that has been uFticially ,tamped or marked by the city ur town may be proviJed to the
:ipplic�nt as prouf that a valid ;iFtidavit is un�file for future permits or licenses. A new atfdavit must be lilled out each
y�ur. \Vhere a hume owner or ci�izen is obtaining a lic�nse ur pennit not related tu any business ur commereial venture
li.a. a Jog licen,e or pennit to burn Ieavrs rte.) SdIII PCf5U1115 �OT fl(�Wfl'tI [p COOI�ICIC (I71):l�flll�V1I.
I�h� �)Itice uf Im-estigatiuns «�oul� likc tu �hank yuu in a���ance tbr yuur couperatiun and should you ha��r any yuestiuns,
���C:I�C t�U IIUI �1�11f:IfC tU ll�'C 111 ��:1��.
fhr I)rparmiene', adJre,s. �rlephonc ;md lax numbee .
The Commonwealth of Massachusetts
Department of[ndustrial Accidents
Oftice of[nvestigatlons
600 Washington Street
Boston, MA 021 I 1
Tel. # 6 U-727-4900 ext�106 or 1-877-MASSAFE
Fax # 617-727-7749
Itc�i;eil `-'_b-U> .
www.mass.gov/dia
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N/F N/F N/F � �� ,^�� `
r�o
J. MICHAEL & ANDREA C. CANELLA &
61 N
CLAIRE L. WHITE—SULLIVAN JAMES COLLINS FREDERICK J. &
DDNNA M. FLETT No. 29422
PARCEL ID 27-0536 PARCEL ID 27-0535 PARCEL ID 27-0534 E "D ��l �`���
� 100.00' �i "I CERTIFY THAT THE DWELLING IS LOCATED
� LOTS 8 8c 9 ON THE GROUND AS SHOWN. THIS PLAN WAS
� I,� PREPARED FROM A TAPE SURVEY.
m 1 0, O 0 O� S r I" c��/:rSr�—.�—�,�—�
RALJ��W REID P.L.S.
N/F N/F
PAUL M. & SHAWN W. MACNEIL &
MARY L. TUTTLE DECK JEN DOMASZEWSKI
PARCEL ID 27-0516 PARCEL ID 27-0518 GRAPHIC SCALE
0 0 � o io zo +o eo
� l ,zo � PROPOSED
12.5' X 12' ( nr �E'r )
2y�Ny�Y � BATHROOM i ��n = zo rr.
SIDED ADD I TI ON
n't
�y15/
I
_ POR� �� SALEM , MASSACHUSETTS
a 50�} PLAN OF LAND PREPARED FOR :
� (^ �
, � � ,00.00' � THOMAS MANNING
0 15 LARCHMONT ROAD
0
�
� PARCEL ID 27-0517 '
� 15 LARCH M ON T ROAD RE�p �,Np suRv�oRs I
o DEED REFERENCE: 365 CHATHAM STREET ��
� BOOK 5179 PAGE 435 LYNN, MASSACHUSETTS
� LOT COVERAGE: R08-044
� EXISTING = 16.5% R`^� DATE: JUNE 1 6, 2008 SCALE: 1 " = 20'
o PROPOSED = 18%
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