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10 ORNE SQ - BUILDING INSPECTION +i*MidWTfEfiLf� APPROVED BY T44E ,W5PZj;TDB PRWR TP.A_PERMIT SUNG GRANTED CITY OF SALEM p No. �f� Date y.. Is Property Located In Location of the Historic District? � Yes x No_ Building 10 OR-NE S Q Is Property Locatedlin 5 A(.6/r1, 0 F1 the Conservatlon A ? Yak_No_ /9 7O BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: IZEMOVE NON LOAi> U40t.16 (/JAU6 — ]WILD NEW bN ATrI L PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name PA'RZ1GtC '�, NAOW GtZAY Address & Phone 140 Moosr VEEP-Now ST(60) ZZ7 -B59Z. jZo TZ)0j MA 0Z too Architect's Name Address & Phone 1 Mechanics Name Address & Phone n L What is the purpose of building? "�1 CsR-r t A L— Material of building? If a dwelling,for how many families? Will building conform to law? YES Asbestos? N 0 Estimated cost I (3 LZ city License x N A a tense r 8 343 Barre Improvement X '4' Lic. t Signatu e f Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE I�EMOVE Ex1S —11NG NON- L-OAD IBEAZIuI, KNGE WAS &yy NEW NON LOA.'D `gEbZR4 KtuEE WAL1S itasl,�,-I� g. F�tlatsµ wt•ru wA�l�o�� MAIL PERMIT TO: 59t�z SU MMi� C7— SAceM, Mrs 01970 L , i No. / APPLICATION FOR / PERMIT TO LOCATION p PERMIT GRANTE ' a 3o � 2f5 AP ROV�D C 1 INSPECTOR OF BUILDINGS .. k f The Commonwealth of Massachusetts 7 Department of Industrial Accidents � 011ieeollares�atloas 600 Washington Street, 7rh Floor � %> Boston,Mass. 02111 " Workers'ComiRens ion Insurance Affidavit: Building/Plumbing/Electrical Contractors ADDIIC�RLimrB[lntff0�",T1 "t.°tv",?t�cr,,�- ;�� c - ,am e: J • �i-x,.t�t ,0157 �VE QA1L —EUKDry-S address.591/'= GU M M Ems. si•�,(A / -7,/�' p .,/ city 75ALEM state 1'I r/t' zip:O1970 phone# "Y/6-745 'S36zV work site location(full address)* IV V f.KXE aQ GALSM MA D 1970 ❑ 1 am a homeowner performing all work myself. Project Type: ❑New ConstructionIStemodel 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition — ------ ----I-am atFeruployeFprovlding workers'compensation-for my emptoyees working on this)off — — --. . + company name ' ' '�' a+ .riq}+ &�`Y£�.ka fi ' �, 2`},q cy^`:ti+�'`y�rb 'y�•z e" .2`% kt{��{`£,u:�, �m,t4 add city: s .'✓ "eo-. w e eY', ETA xy,}+ % °d 1 � y' *M4K�.,d x K}dRT ok" 'ygY "hr.!^& 'ir•` eyy 'Tb { $ OAOOE KtR S" �Y4 I? s& tt :r A q X. 7 ..,yfb— msurance _ nnllcv M ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comoanv name• r address: almost M. �.- 4 2§ �, £ .�'4.".+t 1 4 i w j �.t r xNy. l.s,�{d��fitaFS z�{Nti?"t t •w ins 11,16 FAN, r+, - COniDaaV name; v,y � �, a"'!�� ei t i" v-�' t �Y, N•° �` °.. address: , { Tf insurance M4.d. a a J im ArzY`4'4, Failure to secure coverage as required under Section 25A of MCL 152 can lead to the Imposition of criminal penables of a fine up to SL500.00 and/or one years'imprisonment as well as civil pensltin in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to ice of Investigations of the DIA for coverage verification. l do hereby rlijy Wderthe ains e the information provided above is true anj ccorrycl. Signature Daze 757 Print name _ ?Ok_mQU%S7_ Phone# 978- 7as e67,6 official use only do not write in this area to be completed by city or town official city or town: permit/license# :E]Building Departmenticensing Board❑check if immediate response is required electmen's officecalth Departmentcontact person: phonea; ther I ,,,,.d S,,, 2o)3) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 ajoint 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 apartments and who resides!therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or oc�hcenstng agency shaltwithhoid-theissuance-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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 nt of Industrial Accidents. Should you have any questions regarding the`law"or if being requested, not the Departure Y you are required to obtain a workers' compensation policy, please call the Department at the number listed below. r , z, City or Towns 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 permit/license number which will be used as a reference ntunber. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: F. . The Commonwealth Of Massachusetts Department of Industrial Accidents fllllce of Imesdadem 600 Washington Street,7" Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 CITY OF SALEMq MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA 01970 " TEL. (978)745-9595 ExT. 380 FAx (978) 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-debns-resulting-from the-construction-activity-- ------------ - govemed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S 150A. The debris will be disposed of at: 5 AI.EM 'CTL4NS 5"TATl ON Location of Facility Pzl'T15- Sign.�Jqof Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) 1�ET�e I ?iN'LMQu15T" Name of Permit Applicant 1DNGXA,IL �1711.D6�-S Firm Name,if any 51�A/z SUMMED sT 5M ZM I-AA �1970 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 properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. �pLID �.IN65 �6Na7F- EXISTING WALLS . L4EXI5rING - PlNl5l7 WII'tI 5I1FFrPOGK Tl>iPEE 5/DE5 13A5F60A>PD TO MATGI7INrEPIOF ACLFSy DOOM PANEL IPEMOVE EX/5T1N6 NON LOAD 6EACING WALL NEW KNEE NEW KNEE WALL NON WALL NON LOAD DFAPIN6 LOAD DEAPIN6 2-X4 GONST, PEMOVF FXl5T/N6 2X4 GONST. NON LOAD PCIWIN6 WALL f THlS ROOM TO DE INSULATED AND 5HEETROGKED EVES TO PFFK HEETROGK ROOM 5/DE SOX IN Gf1/MNt�' TO GEIUN6 ROOM 5IDF 5HEETROGK 5HEETROGK TO GFIUNG TO GEIUN6 Ll \\\) v RFMOVF HARDBOARD F/NlStl WITH StIFDTROGK Ttll5 ROOM TO BF INSUUtTFD EVE-5 TO NFW GEIUN6 AND NEW GFlUN6 REMOVE HARDBOARD FINISH WITH 5HEFTROGK f _ LEG T2.tc_� FXlS7-lN6 IIOv Nfw 511OKF NlfW IIOv LINE TO POOL l DPTPGTOP OUTLET AELOW ALAPM POWEP SUPPLY P166Y PACK PWP PPOM ALAPMTO NEW IIOv DESTINATION UNKNOWN p� NEW SMOKE DETEGTOP IFIF-]l NEW I/Ov Val— OUTLET NFW 110v FX15T1N6110v NEW 1IOv OUTLET OUTLET—WILL OUTLET NEED TO PEMOVE IIOv TO GE/LIN6 TWO UNES ,POOH PIXTUPE P�ELOW NEW 110v NtW 110v OUTLL'T OUTLET NEW llOv OUTLff POP AG NSW QUAD 110v OUTLET/PRONE