LEGGS HILL RD - BUILDING INSPECTION (2) No l� City of Salem Ward
' G
APPLICATION
FOR-
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all hems In sections.1,:14 114 N,and D(.
(.
��., : n. a List + y'i1 /�, DISTRICT
i AT(LOCATON) DIS1R1
LOCATION slneEn:
OF BETWEEN AND _
BUILDING ICAOSS STREET) (Moss STneE1)
SUBDIVISION L
LOT BLOCK SIZE
11. TYPE AND COST OF BUILDING -All applicants complete Parts A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION"USE MOST RECENT USE
1 ® New bugling Rseldendd NonrosklentW
2 ❑ Addition(X residential,enter number of new - 12 ❑ One family 1 a.❑. Amusement,recreational -
housing units added,X any,in pert D, 13) 1 g ❑ ChnrJt o8far reagious
13 ❑ Two or more family-Enter number - -3 20 ❑ IndwVal. -. ..
❑ Alteration(See 2 shove) - - - - al unite__._c._.....:_.__..__......_.:._..__.
4 ❑ Repair replacement 14 ❑ Transient hotel.motel.or cbnnilwy-, 21 ❑ Parkng garage, _
5 ❑ Wrecking(X rmrlsla/nlY rasidendal,enter number .. Enter number of units............._.. - 22 ❑_Service salia4 repair garage
......._. 23 ❑ Hospital,institutional
W units in building in Part D,13) � 1g Gore r"''" '-
_ a ge- - - 24 ❑_or5ce,bank professional
5 ❑ Moving(relocation) 16 ❑ Carport. - 25 ❑.Public utility ..
7 ❑ Foundation only ... - 17 ❑ other-Specify - 26 ❑ School.tibrary,other educational
27,❑ Stores,mercantile
S.OWNERSHIP - 28 ❑ Tanks,lo.sers
e ]Private x%et 2 fir.duo,corporation,on.nonprofit yM C A
Institution,etc.) ® - ..
g ❑ Public(Federal.Sate,or local government - -
C.COST (Omit cents) Nonresidential-Describe m deal proposed use of bwWwX ,ag,food prxessing plant
machine shop,sundry building at fosplet elementary school secondary school,college.
. parochial school,-parking garage for department store,rental office building,of building
10. Coat of improvement __._....._.._..__.-..._._...._._._...._... S�D a p� at industrial pam.If use of existing buildi-r rg rg is being cheng'r4,enter!xonnaed
To be installed but not included
' in the above cost ) MCA of Ce9 A ysN AQO d
.. �
a Electracal... .._....._,......_. _._. _. _. _ 6bo 000 �� TT—
b. Plumbing......_.......................__............_..._.__..__.. 600000 F1'Ic.S
a Heating,air conditioning
d. DOW(elevabr,atc.(._._EI
11. TOTAL COST OF IMPROVEMENT S O 0� Op
111. SELECTED CHARACTERISTICS OF BUILDING •For new buildings and additions, complete Parts E-L;demolition,
corn ete on PWrtft J& M, all others skip to IV- - -
E. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL L TYPE OF MECHANICAL
30 ❑ Masonry(wall bearing) 35 Gar 40 0 Public or pmate company w-ro Mere be central air
31 ❑ Wood frame 35 Oil 41 ❑ Private(septic tank etc.) conditioning?
32 0 Structural steel 37 ❑ Electricity - 44 ® Yes - 45 ❑ No
33 ❑ Reinforced concrete 38 ❑ Coal. - . H. TYPE OF WATER SUPPLY - Wit there by an eleretoO
34 ❑ Older-Specify _ 39 ❑ Other-specify 07 Publlo or private company - 48 ®..Yea - 47 ❑ No
43❑ Private(welt cistem) -
J.oBLENs1oNs M.., DEMOLITION OF STRUCTURES:
as Numberotstones.__.._ ..._. .._.._. ._..._ _.
a9. Totai square reel d soo area, Has Approval from Historical Commission been received
ao floes,Dosed m extesar - } for.any structure over fifty(50)years? Yes_ No_
dimaaiom - ...._
so-- - Dig Satef Number '2;hi`, 3t 9n -/a /9
sa rorel mra area,sy n--� 'f_. , .,�_M
K.NUMBEB OF OFFS EET PAMUNG SPACEa »`` ...={r
Pest Control:
51. Enclosed...._.____ _._... ._._._.___ .__
THE FOLLOWING UTILITIES BEEN DISCONNECTED?
a.Y([//52 p'' Yes No N14'
52. Outdoors....... ..__.._.:_............___._....._. "
L BF.SIDEIlitAL 81JBD111GS ONLY .
.. s
53 Fsdoaed .... .. GasGas - ... .._ _.
- • :
FuY
54. Min W a. DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
°�h1°0 Padw __._... :...._.___--- BEFOWA PERMIT CAN BE ISSUED.
N. COMPLETE THE FOLLOWING:
Historic District?__.Yes—, No✓.(If yes,please enclose documentation from Hist.Com.)__
Conservation Area? Yes_; No_--(if yes,please enclose Order.of Conditions)'
Has Fire Prevention approved,and stamped plans or applications? Yes— • No_
Is property located in the S.R.A.,district? Yes_ . No_ —.
Comply with Zoning? ' Yes_w' No_ (If no,enclose Board of.Appeal decision)
Is lot grandfathered? Yes-_' No (If yes,submit documentation/if,no,submit Board of Appeal decision]
If new construction,has the proper Routing Slip been enclosed? Y.Z No
Is Architectural Access Board:approval required? Yes_ No (If yes,submit documentation)
Massachusetts State Contractor'License# a-f 9/7 7 Salem License #
Home Improvement Contractor# Homeowners Exempt form(if applicable) Yes_ No
CONSTRUCTION TO BE�COM_ MENCED WRHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
If an extension is necessary, please submit
CONSTRUCTION IS TO BE COMPLETED BY `"'` ""3�� ,boo in writing to the Inspector of Buildings.
V. IDENTIFICATION - To be completed by all applicants
Name - - Madmv address-NumW street city,and swO LP Code TeL No.
,. S me aA,;, O/9/�
qlo + Spree+ 978_ d -o
Owners
Lessee /• $s�ef� o19/f
79Y
2. GCeow CoaS�s�ul;on = '3a�•F F.SSeK �•F•
SUWWe -Yd 3�35
Contww License Na .
,St.✓4»r S
s. � e (($\ 4- Noc ti bi
Amhhed o 84
7 V7
Enw�
-
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his authorized aaent and we a ree to conform t all licable laws of this jurisdiction
Signature of applicant Address Gr+-o coNc?. Application dateOY
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number use Grave
Building A/m/C,,,,^b c.« 2 8 Zoote
PermB ISSUed. . Fire Gredng
Building Live
Permit Fee $ 1&4 S35-. 7o occupancy
Loading.
Lard
Certificate of Occupancy $ ApprovZ./
d b : pp �
DrairtTle__ $ a
Plan Review Fee $
.__ T'RLE
NOTES AND Data. (For department use)
t ,
1:4 PP
S0-- Cr RA V
p/L N
Cu r
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT _
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN-For Applicant Use
ON
CITY OF SALEM
l� PUBLIC PROPRERTY
DEPARTMENT
tCntaERrBY oaacou.
MAYOR
120 WAS10= MStX=a SMM4 MASSACWsVrrs01970
TEL 978-745.95" a FAX-9M740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrictans/Plombers
Applicant Information P10a..Print
Legibly
Name(BusinewOrseniatioa/Individual):
Address: a tie
City/State/zip: ��'anr���, Wli} phone#
Are you an employer?Cheek tbs appropriate boss
i. .I am a employer with 4. 0 I am a general contractor and Ir[:l
o]eet(M'**:
employe"(M and/or put time).• have hired the subcontractors construction
2.0 1 am a$ole proprietor or parmer• listed on the attached shoat, t odelingship and have no employees These wbcontracton have olitionworlung forme in any capacity, workers•cotttp innnasce[No workers' comp.insurance 5. 0 We are a corporation and itsDg additi�
requite&) oflicas have exercised them 10.13 Electrical repairs or additie®s
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or addidow
myself.[No workers' comp. o. 152,41(4),and we have no 12.(]Roof repairs
insurance required.]t employees[No workers, 13.0 Other comp.insuance required.]
fAny spike"eft ofsb boa el mum am da out of section WW shoving dwh waelcata
Homeowma who aeb"ebb aNldwh krtlmbg dry sm dekg an weir ad thm hhe awulde ooa spit Qu doe. wY
rCaoOaetoea MY obaek NO boa mast■4aofd an ddWwA there dmwfig dr more orow mb4cooaelms sod dW wakao 0.1p
I am am ernpfoyrr that Is providInS worhrrs'comprnsadon inruronerjor my employees Belaw ht tn MOepoBry andJab rise
jormadoat
InsunuwA Company Name: A G
Policy#or Self-ins.Lic.# w e tig F?s-
Expiration Date:_ 3 It o /0 7
Job SiteAddceu:_ �.egai5 N�li `IfNCA City/StaWZip: CLGIU, 044-
Attach a copy of tbi workers'wmpenutloR potley deehsratieu papa(sin t�
Failure to secure covers as wing Polley number and explrsdon dab}
N rc4u red under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of•
Fine up to$1,500.00 and/or one-Year imprisonment•as well as civil penalties in the form of a STOP WORK ORDER and a Ron
of up to$250.00 a day against the violator. Be advised that a copy of this stateso m may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
/do hwebY ersliJye tinder pahu d pe tip olparJwY that tltr injormadon provided above 4 o w and correct
FIssuing
ly, Do not write in this area,to he completed by city or town oJJlcw
Permit/[/tense#
ity(circle one):
alth 2.BuOding Department3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone#
Information and Instructions L
ylassachusem General Laws chapter l52 requires all employes to n service mother under as Y �employe"'
Purwent to this summ an e�epJoyee is defined as ...every Perso
contract of him
express or implied.oral or written." two Or_
"an individual.ParmersWP.association.corporation or other legal Wnry'or to er,or the
oA.f her forego n defined as and ie cludini the representatives
of s deceased emP Y
of the foregoing engaged in a joint eaartne shi l sera However the
association or other leQa1 entity.emploYleg�P oY
receives,at trusua o an
owner of a dwelling home h corm nag �°�00 and who resides therein,or the oaupant of the
dwelling how of another who wP�ys P�to do mainteneme.construction or repair work on rich dwelling
house
at on the gads or building appurtenant
dteceto shag not because of such employment be deemed to be an tenployer."
MGL chapter 152,$2SC(6)also am=that"every state or{seal Ikenslag agency shag withhold a Igor ce W
orsa
too is a business or to construct buRdbW u the eommoaweslth
reuewai of a Ileesse or pennk secaptable evidence of eompi aaae with the Insuranceed•
coverage requir
aPPiiesa who bee not produced states"Neither,the commonwealth not any of its political subdivisions shall
AddidonaUY.MGL chapter 152.$23C(7) le evidence of oomplisnce with the insurance
enter into any contract for the P�o�mCO of Public work until acceptab "
uiremenn of this chapter have been presented to the contracting suthontY
req
Applicub
ompensst�affidavit completely.by checl°ng the boxes that apply to Your situation and,if
flew fill out the worker' c
s)nsme(e),add other than the
re*ce)and phone numbed")along with their carufieste(s)of
necessary.supply rLiabnna�(ility Companies(LLC)a Limited Liability Partnerships(LLP)with no employees
me pntacm are not required to carry workers'c°mpensatrOn insuraIICe. if an LLC or LLP does have
employees.a policy Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ould
of inrtranoe coverage. Abe be stare to sign and date the affidaviL� �
be retuned r the city ti town that the application for the permit or license is being requested,
Industrial Accidents. Should yet have any queatiaoa regarding the law or if you ate required to obtain a workers'
a the number listed below. Salt-insured companies should eater their
compematwn policy.Flew call the Departmentline.
self-iantrm"license mmber on the
City or Town Otiddsta
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.
e
Flew be sure to fill in the permidlicena number which will be used as a reference number. In addition.an applicant
that must submit multiple p mut/lico ns applications in any given year.need only submit one affidavit indicating current
policy information(if necessary)end un "Job Site Address the applicant should write"all locationsrov��of
of the affidavit that has been officially stamped or marked by the city a town may P
town)."A copy or licenses. A new afTdrvir must be filled out each
applicant as proof that s valid affidavit is to file a Bens Fermin not related to any business or commercial venture
yea.Where a home owner or citizen is obtaining a license ere Permit
(i.e. a dog license or Permit to bun leaves etc.)said person is NOT required ro complete this affidavit
ou in advance fa your cooperation and should you have any questions.
The Office of Investigations would like to thank y
please do not hesitate to give us a call.
The Department's address.telephone and fax numbs:
The Commonwealth of Mmachusetts
Depatt ceM of 1ndasUW Accidents
Ofaa of Iavad9061s
600 Wa1qhM9M Street
Boston,MA 02111
Tel. N 617-727-4900 Wd 406 of "77-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 WWWx a LSOV/dla
u3/14/ZU06 00: 15 P'AA SUtl 855 SSSJ EASTERN INSURANCE NAT CL to001
■ ACO ., CERTIFICATE OF LIABILITY INSURANCE DATE
/'10/2 oY)
PRODUCER (800)333-7234 FAX (SO8)65S-88S3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
EASTERN INSURANCE CROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NATICK, MA 01760
INSURERS AFFORDING COVERAGE NAIC #
INSURED Groom Construction Co. , Inc. INSURER A: St. Paul Travelers 39357
324 Essex Street INSURERS: American International Group
Swampscott, MA 01907 INSURER C:
INSURER O:
INSURER E.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INBR D' TYPE OF INSURANCE PoLICY NUMBER POLICYEFFECTIVE PoUCYEXPIRATION DATE IMMIDDrM OMITS
GENERALLIABIWY C0463D947A 03/10/2006 03/10/2007 EACH OCCURRENCE 3 1,000. 0
X COMMERCIAL GENERAL LIABILITY DAMAGETORENTEU-EREZMSES IF, 3 300,00
CLAIMS MADE O OCCUR MED EXP(Any one permn) Y 5,0O
A PERSON ALBADVINJURY s 1,000 00
GENERALAGGREGATE $ 2,000,00(
GENLAGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,00
POLICY X JECT LOC
AUTOMOBILE LIABIUIY 816#63D9481 03/10/2006 03/10/2007 COMBINED SINGLE UMIT
X ANYAUTO - (Eaacadenq S 1,000 00
ALL OWNED AUTOS
BODILY INJURY
S
A SCHEDULED (Per perean)
FD .
X HIRED AUTOS BODILY INJURY
X NON-OWNFD AUTOS (Pa acatlenl) Y .
PROPERTYDAMAGE $
' (Pet acddenl).
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTO OTHER THM EA ACC S
AUTO ONLY: AEG $
EXCESSAIMBREtUIUABIL "If BE4953127 03/10/2006 03/10/2007 E�AcHoccURREHCE s 10 000,00
X OCCUR - Q CLMMS MADE AGGREGATE S 10.000.004
B S
DEDUCTIBLE S
X RETENTION 3 10,00
3
WORKERS NAND WC9688758 03/10/2006 03/10/2007 X M w %Iµ AT
MTS
B ANY PROPRIEWRIPARTNEUEXECUTNE MACHACGDENT Is 1.000.00(
OyFeFICEIUMEMBWEXCLUDEOx Fl DISEASE-EA EM O S 1,000 00
%Q:LLPROVISIONS below EL.DISEASE-POLICY UMR 3 1.000.00(
OTHER
ERTIFICAM HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIHCATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LWSIUTY
OF ANY IONO UPON THE INSURER,RB AGENTS OR REPRESENTAT(VES.
AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA
ACORD 25(2001/08) - ®ACORD CORPORATION 1988
CrrY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
aaras lawAselamsn m sa�na�r�►ruoa�+s01s»
Construcdos Debsts D4 at AIW&vit
(regotred hr ai!dam mom.ad oaaovaetas world
is m adme with ties *On of tbs Stft ZuUdkV Code.780 CDR aaedos 111.5
peibdes rod dw p wAdow of UM a 44 0 A
BuOdhil lrnrdt fi is issued wilt dw a mMm that the debris ea dit Dos
tlds eimb shad be disposed of is a peopstly losond wants disponl bal ty m defined by MM a
111.s 1A&
Tta debris*0 b.ftaspoOd hr.
wl_ Li e Cac�+ hay
tasmn a
The debris wiU be disposed of in:
Ale/'4i,t s:de- 62C4,
2C4 n A
foams of
J I A /4ag Ad.. W- Andove r—
(w1dress of
u rpamir>p�aat �
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0;2i[34�ARID BU °O/REGUpN�3
. ' LiceLATI
nse: CONSTRUCTION SUFEFtVISOR
Numbers p_S
_ _._. 059177
-997D
006 Tr,no: 27529
Reb"{r ,I },
CRAIG LANOIJE
78 SEVOIAN DR
0
METHUEN. MA 01M •_' �%„� /� -
3
Commissbner 3
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Workk S 6o(e. IMCA
Le3�s Nf"11 tZd.
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION XX
CERTIFICATE OF OCCUPANCY
LOCATION: Lu265 b kLL �b. DATE Sfepl 2no C�
APPLICANT: G r a o w+ C mlaAra t kS on
ASSESSORS Q 0 _
FRANK KULIK + F='-✓�/` DATE: \ (7 O
(93 Washington Street)
r j
CITY CLERK
CHERYL LAPOINTE DATE:
(93 Washington Street) /
PUBLICE SERVICES Cj
BRUCE THIBODEAU DATE: O
(120 Washington Street)4 Floor
WATER
DOTTIE THIBODEA DATE:
(120 Washington Str t)4i6 Floor _
CROSS CONNECT SUPERVISOR t
BRIAN THIBODEAU DATE:
(5 Jefferson Avenue)
PLANNING
4X RWA4
DATE: F
(120 Washington Street)Yd Floor
W�'Yk vIK c�lha- `I'kat 49Wk if �Pl�.{e�
CONSERVATION COMMISSION 19 (.
DATE: to 3w� S zct7ln
(1
[0 Washington Street)3rd Floof I
ELECTRICAL ___
JOHN GIARDI DATE:
(48 Lafayette Street)
FIRE PREVENTICINp
ERIN GRIFFIN III A4wd LtK& DUri_ DATE: ` l y b 16
(29 Fort Avenue) e
HEALTH f
JOANNE SCOTT— IXJ DATE:
(120 Washington Str 46Floor BUILDING
THOMAS ST.PIERRE DATE:
120 Washin on Street 00( gt ) 3
Al
�TT -0, Massachusetts
City of Salem,
Fire Department
A
48 Lafayette Street
David W. Cady Salem, lfa.ssaehusetts 01970-3695 -
Chie Tel 978-744-1235 Fire Prevention
t.on
I
978-744-6990 fax 978-745-4646 978-745-7777
d,odyC (em mlsa .ca
August 14, 2006 _
Chief David Cody
Salem Fire Headquarters
48 Lafayette Street
RE: Traffic incident Legg's Hill Road
Dear Chief Cody,
On Tuesday August 1, 2006 there was a traffic incident on the box culvert of Legg's Hill
Road. After receiving your call concerning this incident, I responded. I spoke with the
truck's driver, Mr. Derek Logue, and took some pictures of the scene. The following is a
summary of my notes from the conversation and enclosed are copies of the photos.
811106 Mr. Logue, driver of the Webster Vet Supply truck, stated that upon accessing
bar culvert from Marblehead side a car was exiting the culvert and because of the
narrowness of the road he had to "hug"the inside corner. (Tire tracks visible in mud
alongside Jersey barrier.) Passenger side rear tire clipped culvert's side edge and
caused truck's drive shaft to "snap." Driver stepped on brakes and truck wedged into
Loring Avenue corner of box culvert's side edge Visible cracks in culvert's side-
Salem Police notified Mass Highway far inspection of culvert
The truck was disabled for quite a bit of time until a tow truck capable of towing it was
located. Because of this, the culvert was open to only one lane of traffic with cars
traveling in both the inbound and outbound directions using just the one lane.
This incident simply confirms my concerns of vehicular traffic burden and the ensuing
compromise of emergency vehicle response capabilities regarding the box culvert of
Legg's Hill Road.
Please accept this letter as confirmation of my reasons for not being in approval of the
development of the Legg's Hill Road YMCA Project.
RespectPal /!*-
,\
Lt
Fire Ma
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