18 LARCHMONT RD - BUILDING INSPECTION I
AW- t/v CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xwwjus t t>ttacati
Moron
uo a•As,�r�,�SraEW a SALEK MAUACNt=ns01WO
Workers' Compensatloa Insursa¢e Affidavt; Bnlders/ConractarametMd aasPlmbeaA
Name(HuaiaesuOraaaihpoaRndiviAul): N6t� ,nY C�
City/StatdZip:__Q,4,azs M-4 Phoned g78. 71�• �23
F;am
Pleyv)Check the approprlaft post
loyee with 4. ❑I am a Small centraetarandIType of proleet(requtreo:
(1Wt and/or part-time).• paw hind the wb•cononcton 6• ❑New construction
propriety or permer, listed on the attached cheat t 7. Q�gemodalig
w oo ampbyeesThese mea . ❑Demontion
gor we in any capacity, workers,comp• �w
Q workers.comp.insurance 5. We are a corporation end its 9. Building won
otlkers have exercised their 10.0 Electrical
11.Per MO
3. 1 am a homeowner doing Ali work righkt of exmnptiou L lePatre a �
myself.(No workers'comp, r ¢1(4),and we have ❑Plumbing�rs or addidoor
insurance required.)t employees,[No workers' 12.❑Roottepairs
comps instance required] 13•❑Otbar
;Any W dcnm err ebaeka boa at aaor ales t10 ors the aaNaa 6dow'k+a't+s Ask Takata-
t Homawo�r who A*"Ms dlldvlt' eoegwmeaa
rCaaetuYoar tfae ebaek ehls boa mart araear ��oak and�tdn �� dIIdevlt tAovle/tlraameotar��eaarc�r� �°�
f�masloa an entployn that 4 provid4tg workers'
In ar eomPensWonuerareeorj my s 4 eeployeea Below 4 LU
Polka'w//o1.us'
Wunu ce Company Name:
Policy M Of Self ins.Lie.M
Expiration Date
Job Site Add<at:
Attack a copy of the workers'comnsa pedon Ciry/State2ip;
poncy declaration pap(skowing the policy number cad expindon daft)6
Failure ro secure coverage as required under Section 25A of MGL a 152 can lesd to the
fuze up to S 1,500.00 and/or one-yew imprisonment,a,wen as civil im�tiOn of criminal penalties of a
of up to 3250.00 a des a penalties ate in the form of a STOP WORK ORDER and a Nye
y gaor i the ante r r. ra advised that a copy of this>titcm m may be forwarded m the Otliee of
investigations of the DU for insurance wversp verification.
/Jo/ureby Or tAr pa4rs and penaltlq ojperfnry 1Aar the injormodon provide/above 4t ow and correct
i2•�J
Phone
�' S23
Of e'd use oa/y, of not write In this area,to be compkied by city or town OfflCi L
City or Town:
Issuing Authority(circleone): Permit/Lleeme 0
1. Board of Health I.Building Department 3.Cltylrowa Clerk 4. Elec
6. Otper trical Inspector S.Plumbing Inspector
Contact Person:
out p
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 W.\s'11INGTONSCREET 4 SALFM,
Tr,j:978-745-9595 #FAX:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft -1 - --- is issued with the condition that the debris resulting from
this work, shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
M _ i'Nif t--k
(name of facility)
t address Of facility)
si-liatuic ofperinit applicant
:ailt
r"s+"`" t.a,�'�it':'7$ ..`ri�M1�i�'4` �'�kfh T��+.v,',SIF� S�fr"ir� :'ren tY}k�3�l t'"aw�4��Is•kr ,� elvnwn ,Y4 'Yd�fr �,�,y+, r,�g�
6 T tune le :� * e 7" 5d A 4 rf� 3,r tr s � r�1 't�`>'��a�,E^s�' 4 �wi..u'�R.f3✓^z�so tl� 'k"1llti''ty4�s���` Or >d2r f'4'�i�..
f ly�jA'�y�., � � R'' �e ;' �i✓i ''yr 2 J �, F u, aj M�i,d r pr, rYY I ru�,� �, ��yl..�f'k��,m � �f i4at� �4%1.�1J81pF"� L1FN"'fif� i�rm'jM C'ir f"ly��".
��L' e( , ��i
r�ry_t „ .r,f�r k�, Sr j G 'kR J r A
J`tw"" `<p°r r Wf>•F£5 6`n +kb¢�' 7.Jy4 t' ✓f !. ( i y
� a>F� ,,..., q 3rc�✓ °3� nt< ..., t r `. � n; t pa$ tY DC.PY "`F i� � 9 r t SY rN lf M fl`b ti
i ar KSY 41� YiKI n5' - hn Y } J Y' rp 'n�r£51 4 �+ya y5 I JI y�
�ASL�CJILShT15019T0
F�e is m 4�l-ti'� n Y'r� �r� '�� d 1` set) ',f i TIi .��' 1� h.'.k,Nyx+, {n nt Y+V' i t` x t ^. .�h m,� e ^•k-1 �',J (AK � r PN^ tit,
x a ePLIC�t ONFORTE REAYR:�RENOYA �� r=t
�� �DEMOLITION:��OR GHANGErO� USEyOR k m �� �'a�—'—�
a" r��a 4 £ �� CT OR B ' CI7PANCY FOR ANY EXISTIN �;,l t�� ,�,
d`G 719it 1 '' ` r7,.>F' u f $-a �' ' 'i r STRU a `� a �* ttn a
n "enxe d „r9y I o- t IY e I �� e ! hef a 0 ,),�'
i9.y t 4.� rite 9x_F 1 t" . <i � 11�ue �v� m ,rt mrf°, k �,w.
y�dF" � i
E,NR"i �:
a ; '
$
I m � _
�r e; �G= �i a. . Y 'tJ�rm
�.�J LWII NaRie f "K e F J - syr
s , , �+-m a ,; £ tBu1lding � SlD IJ G' �;� -' 1 .;++t" e ar' }�' "u`' ,01
h JJ ri .£fv 6 t "4tM x t a tt e y. _ a K �-ro }�" ,r� y,
j✓4m�7�sr via �.. r � re$ f�rs tutu rt tC M r ✓sk h"7+ e�`�� Jf +{ r _,#~o I xr A'�3
d x✓r _. � q x1"t�, he A� 1a�e eY E�f d� .j h°� #4� v u{: .� wa � +C7'"ke4k 7 �T✓I� >3e ^� �''` +," �i`�i�' '!i s#r'"I KtJ a'i °'��e
��'�sl[
s+arh'r x'^' �"r rr a11x 0«1 IJ'r , .z r�= a £" e> t �',rdr :rr a Z ` ip' w� e7 �; �' 6 sro 4 Pan d s
d r 7 , I rt wtxti rr�rk,,4iYc`' Cfi!r.JS SY rh
Jrr '' _ PropeKy(s kketed in a Consenatlon Aree<YM °'Hb icbtet»ct Y/N " �I
y� c,� it s axv e b J e � r Kl
TT `-hlwx�n�5�7u ] s. r x rc 'ki C 41 e �Iw'".xPSR,a' 3i Z�rr_ �f,� m � �T S
k1"fh fit" } a aa' si lw <a a' r✓' sJ„i Ian a� 'aa '""a'ti PiEa Y ',/.Ir eU„ mr-.
,i.FY-"2' i j i,u. u A '`y�j54/9j ,'f'tnt 'ie,.� fq
t r �j r n' -:,3 m $��iRa{ � �g
' o rtr k4O;�WNER3HIPeINFORMATION �r�
t Y a -HM w +
fi41�t�fwT
s 3( t i i t
Is. +11 ,, e � ti Z 1,OwnarrW LEA t # i tr n 5JiivwlF�i^a W i ! kx aka } "` y a.�,"l.hd Fn k {.wa, e4r h ;u ,w�.- i ys yet^ ru%�YY m� tt
a9YmF1i dYK t e a• uv 4 '3+] r t< K., dt 4ikrhN �':P 42�"`k- li d4}4tEi�YTY° kNN' ^t'�.J `'�k �4*}r�bwYr�ka �1�25ry.
w a 74
!` -u>; &J7a✓- t,e taw, J .i {rk J Aa7� 9.r" a ear '.ga
�.' }+� >, iaa Name' " d f e f� }rAn ty'�'ayyx r MXr'hi�-f 1 M � '� '�� � rr n �SYt:��`1,n a�✓p�<
T t Yfny 71y1
Addiee� 5, a a u�S� sI
t .a .Y�1.d i'�' Juk�Srm txa . S mr m,iee "Yti�" Y4 i"''m�a nr4� 13^i"0n^ it-�.�, fJ ire +q.y'VV,�q+lr ni axe<c}�`l,'�', YS yr €M`r �j2��%s'
ai �
�7,+Y '�,' 4�✓o'jN' u �J wn 319 m�fk rr¢+ � r E Sr+ x n hr 9�h�.nr°A�"t J 'Y'ruJ,�St'u '
Isi
� !F 41 �A r t; sayer
4 4 ,r1� �'a i T w P rJ rP r>P r u �r y Ss�oL > .+Lr'� �. t-"i iYr'r4 '� Ft" s r• '") 'f'`PW' iI',. A°d" d �; .
rx ----------------
w.S
�� �� x e 3 0 C'OMPLETEeTH19�SECTiONr FOR WORK INS n et i
rk,t J"k' y11 F�f!- '�'w.'�'�%^��� �TS�� L'vd h>• ! ° C'r h'" ° a i 3- r .r 5u f 9y� �k�1 Sm,� sy �,k'r+ry lKhy r"A
}7 P, �rF))y �� � �.r w �r,x 1 +;z�+2 r ,� -n5 ° airi �vr�� � rn�Kh1 Fly � �,. '�-��` ,.-J,�. R"tt..R ta..t �,� '� +• ' "P r3�
t
� W ,>•
�gilY e � ve +� r'a -tip"'` eYe+s `#`» �s 1xeN I u ITr +gym fi. k s rrYFwRp§�
Renovation, ,
ra
kr yy� a {z�Ip rt NLiry`^ t1 y J ec �`e J +: 4 y
ttn"tq e V,A,'IYitt,��(g F, V' t' ' : 1 q am !x Ja e+r J')i .,$ 1` xs3 r T A 6"
+e SN q a Change i.�h lV� V atsmu " 1 p-c >a M : .�a " < ✓t t l ri TFr Llsa�' a 1 ) H''�C �Y R
'3'tti.P*F>=9 -�,�� �E r.�, n'fr t+t'" �a ti,4 ' ✓� J" ti`�!.m �i.,:w'---du q✓ -i � N8W'F i�tr b�':dt �°-�.'�� �`�� �a2rc� ��iF�ze�xi��`t' -c�°'�.1;
e Sf ,SiY.,✓Y 1rJ ye2>!;TI Etta§ "I�rm ,r„ri a
e v '' +R - aCi r i A '� 4N r,ra! �' I rI il�µJ i trJp t 4f FY 's y. aF 'k'tns u a r ��'�'� i `lil Y.
rsr, @(TIO�IuOI) ,,�.i+ nr ,} �!rMi K < y �,, tif` "R> Y b f xrr.£{ n r V f� Y .r hait:1 �� ;
'Wr r'^w, r, f'Zt, s,r eft J s r kr yay Ex�sUn/� ," ' i", '3"� * �' �6 "aii';x �'m'' , 4 +a` it
3� 1- r t# s.? ✓Ea.;s s'(_iy+ � , # µ' e �.J fail 'T't1F'tJ
m J
�
�. x d i ✓ r y. �. n y t,i.k� � .. .,I x
of'j fl00 S ,.3n x w �I §
� 9a ! I •7 4�i it t}1 f�1`16 ate;7 '"'.+ k .Jc`r` F ^' i v m �r•I j` -r k s 17 B x
i COn$1NG1IOn C�ien0Yat10n kshe� "I
e firo .[awx +up.,raart:,?� r4 t ✓ e �h e`�° r ✓.� ✓ e dT�. r,J.. nt r t c' r -r u r a J
3 i
� �
5 }0 � Ina M }e wa rLz YYe aI Sk '3�i,ie u+fr la.6t Ix�12 fY hwK"Y�`� 4ot �'arl` ay� ,Y� ��'' C'�` „t
u G x R3
kn n r�`+;�`4sK 'I"r '�6wrK t4�n rid'%i J$M1aa' 'namti 1"h I "x d' h Y i s m ��v �yrt�:
�� r'rggax m �@SCfIptI0nri0sdf P Op0S2d WOf�( y} i re e✓aI r i a y f d
`1tm �
r�.�,k
u C uT111
'q R /daDF�i '�I LXI Tti rJl� r Oj11 C oo}7, ,t-t LslG�I. AAy kv$F r i il$����5��
o - a y ,v s "W *e 4 r r Y
� ttif- 1 a 415 Iti `
r r nJ�
PL ° ROUS Of.T ?ALAlIC�',di ash }ZOU a, I N s "xtlr llE r e � 'i xki h e9t
f C�BP.� it S Ti-1. N I� asd
7 'S�f t✓ �! &r ¢ J '� '. ;
a ' c T hi4Y 4 e ;•ry �i r �e r 7 I t t i �yilsYY"at(. µ 1+j
u'�' f *Y !ti r'i i�''7,h✓ �✓ � v e J �' l�, �' r qF' r s' x ail }'k es`r{'e i,rr 2} Jr lg }lw x�'a
[�'�yy d }`•�µ v f �' � s i { � K ?J h �i 14 f a m a'T r cif M1tpye�3 ! � ��r}g,,���£tom u.+'3 i�i
�EAi�'ti��� q$t ' e�Ih'TU7L�� + 1:a� d'(ta 17✓/.� ,Q)J� ���st�� iz"e i "K,• � r ' i q�J�,a+v',+$b k vauift r; ` � iF het}1 '.�'k' #Fy
y�e`igCJ'e�;; } wh - ,.k i a�*r - .H.Yr, _� ,�✓'.r1�y aJ iFI ee e�Jr IJ1kx..t +n a� j� �<i'k w � �F�t,S int't : tY'^t l"�„ 3d PTiI �! bse k +le
e����
�
�1�'uid"a'�kuH�'i�e
p IR f I a
x�al.
#�
�m Le+d�WFt�kn.� f,rirl1��>v.; ���+ekl,.rte>.?��f,u.�.�i..s$reP41„T.eMe.da ha,� 9+,S�lrv�..e' Nnrr$fix, da?fl`m ) ,�!. <r¢ RD'Sr v'�1+r„M�i.wNx rw>frcc.>w'f,,:.1:,Lne+krs .nYr,n�..umYLsA xa+i�ll r...n�m.w+:w¢:
Yry '�,°��ybaM'��"x What is theeurrentuseoftheFiuilding? ��5^r� � ��iN7LN' ��StUYnIG� r�' �r�, , «c;e,,-� =, „y��C� n�
�G`Nx',gx., kMatenal{of Bwlding? 1�.�� K dwelling hqw man unds?
, f+!
NBme,
l u I4- 1 r c a t a: r 4ti'wt 1 h> x99�'?
�I J°p K�g s y,! s'♦W VV44a4E '%v '4 ��SJJR�V r ww all tZ 1" �i �•^^
esaYalN rim, 33di
w N
rhrv4 r ' ^ W�'a rl rI+ 7 �4.c� ri rV� l't/1- -PG✓fl��r� if 71n itnlV{"FI} f ri a7t''YJ x%(�Y 'f
Mechanic a"Name
.u; 4W s r�,ns m 1, 'n'w
,�} N }a'r ;Ih 4its t 4�1'v iV "'1;t hVY
Address end n6' Y
.�'+vr 1 In aa✓�ir �krt#;Const,u dn, upooa�LlWise
i"N ^;£h b r ' I'qr ,ch'.v�*Nk'�f+�+ w ffi,�s5^tP'CP�' �r•�Sk�+.�. �.gy„ � �} �° v�`'f x�) �"1
ckr6'" n f t ;Eg rz lf,rav 4 xr y Vi f r W+T,� h, r r tlM r
IJjet N-�F�JS t x ,v .k kt f'^ r"%,a'xs F i 4, ]lr ,Spy 14� spPe�1{'F�CYIYUIiW�� wd° 1�4 'kj�r� ifs �Ur "fl/ �yY[C'Jy r.rvi r��M7Jk
Estlmated,Gost of Pro ed S q
Sryq"#ny�4„�'Yt�tTMI� t :t•.,,Fvyr j
sY �3 � fd hw 8 k 257 x � l ri , {I r a Il t Yd a E4Umated Gost'X S?IS�000 RBa entl8l'c r .Nr ,. rV�{.�
upenlH Feeyf tek�'�j'�
,r.
�� :r
�Y;S � t'
r 1 +� Y✓� 4"v* a , f; t l na , Y � e e 1 r r 't+9li N�r u
;im ' 1 '*,
14x df W'(S.mki.Airy i 3w' 5 Jt a%1�t m'`I ) r n C k G . 1' a 4 4 4f7' r.' Y1' } ir'l yw�.a,P„'"WF`wra J'+NY ;pa �r�t vSy,:rhxh"'Yup.N
*le ktl 2 a�r r '}SZ r{ 4 n >, r t s )c 1;r si t - a ,'W✓y�atiS'-i)�K '}i r5^ 'rf:'J_'aKC t w IFv .kk}I N,
/�l: e n ,3,15 11` t o xa S's k {C d 4 s,vs, e� r q 5 7 1 "nJi
s- r'�SC t1w {a Y i ,-. - t ta{ i r 1 r{ } f ,i l»#'ki FrN, 2�,t x ' ill ib old
{ rf ,Make sure that all fields are properly ands legibly written to avbitl delays;in processingba> { ,4� ,rw ? sr
f G r' n >xti
yy.�J` 1 i lsX )'N r q p a t ; r f Itl
a .� c ; f y �,t
�r The undersigneddoeaherebyaPPlyforeBuildingP k i tatheaboveastatedrYt � 11s^"
(a�,�?j.'ax�tl p}i �u✓Ir *>, �" � K r i}W V ; "�'f � 4 t' ,. ,V �t'�y, =y wr. ,��` a"gf'vh k r� �'N ";�" ',�
� it �:�,? rl ri>✓ � 7q I IgSirF a .� w,k.�� S w- _ a � p X!r r s Ra4. itl r ht vNi�,eu lu ' -ry h $^ 3W,k �(t
F
Yr�{n L'. 'f4'rSP:"+S�'�;ay .„..'"' ai{ wi>cr'SJr &t. rf rp;$'fw r yak try°3 wd ktirtl y '"4'1R mt'. a5N1 ..� 1 H �J-4}'t,.v4:v�' ` q+i3' .St`I�t ' w'i`tu) - >fii}v,�
:Yg Z`id t1
��lw r w�bv..,� YR` �i.��£� ;It°Cr`a�d'v�,fib�i�, f: a�s,�i aa��r'x'�r '�r4 r' is ik�t. ,r�i�2r��� W6 'I#''�' i1� �✓'�i�rrr ��,; V,"'j!"'q vr'�' '"Xi�ii'�1(I WI"4;
p��` j'�At�i l�m GfK� ��`r'.�iY rd" iiY�b^r{��i� sb'�i'f�rtf 2�171r ���F is �'i arr+st IN ly l""*rr�{Wv , ildJt ik fly. n`vWq yk� � J� sarvq+wRS b�'£ H zN,dNk Jllf��>�'(F'�'�h '�� SRrq
i Y� +I}i-,v r mt� ' � Fl�hr (r� +.y rxWW3i i rF M 1 kl dytl-� gga• r1,YjW. lute fI �4 n_k n�tn�'fsC '4 , �� k, Y1W� #�`I���' >' }
t
1,
GI,,��,
��v^I ry+,n .f},�•2 �r k f�$ 3� ^� `3 4 .^l�' '# rc w ,. aE L. y I ran b �R�t,�' ,ui' .� q}S,ya"4a.��1Wr �Nv11;cf' '.
" �1'i4 ��4•Ctil Y'yMY tr� a � ^���}V #1 P� ni -„ i . �rJ1 f .e � 4 `` � ' . 4; r� �q ! fir J'C u�YI�� § � 1'+�
�+u 3v' � w at i w bn �•.rs t
+ 9 hq , a 1 a. S r ' ,?" r +,vCr `�,r r 4F�t'+ b I �' K S 3 Yr �,�{ h ..� '3' e v��•.
r3"j{,��
#.7ew S ,, 9I� t+a a� � "4 x `w.} t r 4,,F# a � '1't"`y., a t �, t ttN s� _. are � F z m ys .ru, , rl.'�r uW r✓' r
; ri}s z� W' jrr f� �r��� a ��q�'� r1�f �r .� y a � 4�ff'd ma44 tK �Fn;'k ter.. ,rr"al "�M^tb'�W�. �lw�y 1�4?I �i^"�xu°ril&n�'"ti'l� �.t���, � '�rry x�'ifl�' 4'Nr'��,46ur•
r �Y � ryP x
t;i
'rye-M n�i�7n I � zYw� r}t 14 ' i4z�N� Fda � r.p a
'a k }
4 f- �'iL
al I
x ,x .t rf a,r! rs i{ u tTMl ryes yy^A r al �,h 3r' 1Li e 3TJ.y "' , f1 `WYrI tt f�1
ry�'yS�wt Y,�. frn� ale 4�,fwIw U.
�i.r&r -§�,n3• -�'tfi1 `^�, 1, L b 1 r�>.' c�' �h sr•:. C s :i st, � C'�'7� 4 � `* a.� wY "� >" .!i �'r��`��PI� u�•+`�' V'
r^dr ,i �11AWv'F
9 l g" f ++"+u,y pr Ni"tIlK
I ',aH w a^4' 1 I'+i>;✓` d �+8� ,3 .If`ni.°rrk 1 S'31 �^ y
i✓{I'?-b., YaY15 ES I� °i),. fy ii ' F{ "i u4W i� r4'iiii 'w!i# ,} vti yl yi
}'W�' !a` k x "v'i"�4..t. 'L 42yt5IK 5.,g �n"�,Y It tl" r S� •r a W sYr
$`, 'T"am r,� ?a <TOfiA�' y3 Jy ti 4� >• .11 �� 'r`3G�rv� # a1' 'o+, }s'hin
t y b- -,�. 71 1 mt 0 rW� t4r e L'' n e�y,� :
IA
t l dR �Y't c ( r�a'Q t N s5 � fw 1. 1 � S 7 �0 � n Wu -�».§ a�411T4r�^ytl ,fir �a�n^F�'t�r{�IA r fr'q"6�1§ »' rv'Y{r��r Y� �. a b
.f .«'a 'Y4a
V M1 1V hl f V v rar b r i`44' MYI F 9a tl f? alf ' N ��t lF.Sa ' V )-�ff,3
1rn 24v'
NJYNt
Q ar e r r x
c a bJ tr n r. as i fa hp d ".py' h .e, l.h3 Nh�t
L�}}rl rl a)a` 1 Iwf.t� x/e )'- � L4vYr rty`f�3✓�y {r pJ Y
a a
6T
P 4'i e Ili 0�, y�D "� #ta 3 f�f 7y Y i 1 »? a 'Sr1 L r• Ih`II �k-Mi V Y 4 r}4k Y1 1'°It it�i�..
r " '� 3it flair 'at9i v,J kb�', �",kr d )R r � f ✓ t e a h a: r M c r , �.
"RUM
nkra' `r�Lfm
w'ah'Yn H N
a.k�-h.avvn