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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED /.
Location of Building 3 TY � V/�O) /T2 42*
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install Siding Deck,Shed, Pool
Addition, Alteration Reps' Is Foundation Only, Wrecking
Other. t
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of BuOdings:
The undersigned hereby applies for a permit to build according to the followingspedfcatiang:
Owned Name: X H o7,j t>A A wri Ro ontractor. po n-A� AJ (2 c>i
Strcet ?A WAeity t Strzx/-f; NWT City 06,;eC£5ieg
state Phone Fj7f) 7yy- 9/ y9 State_ phoneQ7�> 7(o
Architect: City of Salem Licq
Street City State Lic# MP M
State Phone ( ) Homeowners Ezempt Form_ ycs_.Lno
Structure: (please cycle) gle F 1 ly, Multi Family N Other
Estimated Cost of job S 0 , J -7 6
Will building confirm to law? - ves no��'�
Asbestos?_yes no
Description of work to be done:
Drawings Submitted:_yes_ no Mail Permit to: N No k y
Signature of Applicardon— 0NED UNDER THE PENALTY OF PERJURY 7-y, 'q S60 Ze,
CONSTRUCTION TO Bik,OMPLETED WITHIN SIX(f)MONTOS OF PERMIT ISSUED DATE q
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Department use only: Perrtjill .�,: Zoning Iifapll of
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Permit fee S
COlIMMS:
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
• J
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
FAx (976) 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 R S 150A.
The debris will be disposed of at: 4-)LI 5 G KFf N W 00b �1 y�0(z CPS'Irt 2
Location of Facility
Signature of Permi App cant Date — --_-_-
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Aor✓A t i
Firm Name,if any
5u5 (�� ,n1w6o� U�DeCf5-re
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 property-licensed solid-waste disposal
facility as defined by MGL cHL S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
If www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Home Depot
Name (Business/Organization/Individual): 345 Greenwood Street
Address:
City/State/Zip: Phone #: 9 2� �9 -
Are you an employer? Check the appropriate box: Type of project(required):g
1.a I am a employer with S(-,) 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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
camp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing then workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such"
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
.information. n
Insurance Company Name: /Ais _ l i) Df7 po " q
Policy#or Self-ins.Lic. #: 5-S// cf 7� Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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$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$250.00 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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Suture: Dater
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 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
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
owner of a dwelling house having not more than three apartmentsAand who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenapge,;pgns"ctiRn4or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
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
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the
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 Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate 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 permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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 affidavit 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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7-749
Revised 5-26-05 www.mass.gov/dia
To: Pages of 5 2001-6-�O- 11:43,21(GMT) 19784770451 From:Craig Bericidi
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WINDOW SPECIFICATION SHVET - spec.sreI I
Date: -71SL�442
�f I ob consultant:
customer:
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Existing Window
l2 HingLocations
mauft Grids Pattern paftn I I Window ' I
&Glass Misc. I -I
Items cierri,CFC:say,5—,
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single window mulled windows reQu,multiple grid patterns,moicate!odation and pattern;,:ne adeitional spaces provIded I
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Fur C,Ims.CPO,Bay or Bow,use"C,-R,or-s-ISeb,hary).For Palo&Garden Doors,use'S"(Stationary}orWI0,peralingi.
GARDEN WINDOWS
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SAY/SOW WINDOW WALLTHICKNIESS' (inches) %
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p,j.c6onA *Pay:30-or45') D
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Ildth of Overhang('Wh-S) I SEAT130AR D MATERIAL
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JSpI SuCh or Oak Veneer Irte F.Ogre
S,stboand Mears-Birch or Oak If tied to Semi,ecter of Soffir rl
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and agree with all of the
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3 For CSI CPC,SaY 01 Bow,Use R,,or'S'(Stationary).For Patio&Garden Doors, ,se,S,(Stationary)or IX-loperatirg).
G"DENVIIMDOWS
SAY I 9OW WINDOW Ir Wind,,to Soft�inches) i !�W�ALLTHICKNESS' (inches)
0 MATERIAL
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projection Angle:(l 30'0145) S_J�TS
tATSOARD MATT ERIAL
Width of Overhang(inches)
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11 bed to Soft,color of Sof,limaeral I Spec!ry Rich or Go' tee,or White R
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New interior Casino BaytBow/GardencRatio Doo
tntem is that II will W,--eo,em- dor.
tiannshelf(CL)orGolonial(130) 1 have revIettied and agree Ill all of the
job speciffications described above_
SPEMAL COMMERATIONS:
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