66 ORNE ST - BUILDING INSPECTION -pL-*NSIdtfST-9E FIL D APPROVED BY T44E
.I Mp=TOR ,pFWR TD A.PEAMIT $EWG GRANTED
CITY OF SALEM
No. f� w .h q Date
Is Property Located In Location ofd!i1C St
the Historic District? Yes_ No_ Building (O
Is Property Located in
the Conservation Area? yak—No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
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 ��r t^ci �si ��-�� �
Address & Phone �Q� q l 7 14 J i i
Architect's Name
Address & Phone
Mechanics Name B aan Jih,J)uln 4 � 4
Address & Phone ���� y
333
What is the purpose of building? 2
Materiel of building? If a dwelling, for how many families?
Will building conform to law? YIQ Asbestos? C,5 40.7 3 3 )
Estimated cost /'7j 0172 City License k N A slate License 8
e I provenant I ' i �
Lie. /m03(� 4/ � /40x Signature
of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE _
�'e�/a�L�-ruse ���r/h�a� �r�l,�cn-�� a n�( •COz���
MAIL PERMIT TO: 72 JJD 4M Y 22W O L
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
1 -7
APPROVED
*,,Tg- R OF BUI INGS
The Commonweait ..9fMassochusetb
Department of lndustrid Aecidenb
Offl"of Innstisesbas
600 Washinston Shed
Boston,MA OSlll
st+tvtnntass j!ott/dfi
Worker'Compensation Insurance AiHdsvit: BWlders/Contractors/Eledricisns/Plambers
AnDllcod Information Plaa Print Legibly
Name
Address•
city/state/Zip: ��� N] 01 ��1h
Aroy6u an .�anlfter?Cheek of appropriate boss
® Type of Project(segdred):
1. I am a empbyer with I am s vismal emwacew and I
I empksyaa(ha asdtor parbtame).
• Lava hied the rabzcogmc ors 6: ❑New eoasttnction
2.❑ I am a sole PmFietor or partner listed on the attached sheet: 7. 8Bemodeliag
ship and have no employees Then sub-aontrac0011 haw S. 0 DemoNdou
wodit fits me in MW capacity. worke{i'oomP. msoruct. 9. Buildin addition
(No worm'cozW inswance,, 5. ❑ We a[e oosp4 pa s� .
dj.,
ofg 10.p Electrical repahs or addidow
regsire
3.❑ I am a bomeown:.doing all work sight ofeie' p p Mkt. 11.0 Plumbing rgw*s cw additions
myself:[No workers' comp, a 152,41. as ae tiave`no 12.Q RoofrePabs
ioaataocerequhv"t. emyloyea (IQo'ow�kai'i 13.0Other
comp• reivanoerequted:�
-Any eppnCM UM ohceb Lout UM AW cep WAUM MM WOW awriaa%*I. or}�,%mW=Mp„v0HCy
f xomeo.yna.a4o nhmR am SMMVU=Me"faro=4=4 14 w0*=d tho eJis`oofdd.apawelas moA wbmie.am dBd.vit* 1, - och
icons.obse3ia�haeletld.b�`mitutrir.ere.adntuod.erotaa.��.mnrer�Y .aosmet..adc..•waRswliermt'oati�eaioe.
I eras cell srnptoyotlut b peovtdbta wer4ers'eon�psnsartos burtt+rnet fa ary�cii pfo{ E advw b dYtpa7e7 a;vd job afli
Mauaance compasYName:
Policy#or Sel[ins.Lice# Expiration Date
Job Site Addtaa �a!o�1�aZt . t �ia�`m 4t///CriYlStatrlLiP d 2d
III Attach a copy of the workua'compensation Polley dedaratlon page(allowing the Polley number and esPiratioa date}
Fagot to snare covesage as requhed Hader Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$1,506.00 zwor oneyear imprisOMOeat,as well as cid Penalties in do form of a STOP WORK ORDER and a fine
of up to$250.00 a dry against the vioLnor. Be advised that a Copy of this statement may be f warded to the Office of
Investigations of the DIA far fimumee coverage verification,
I ay benbyural�jr a�ndertlFepbsr and peaaMa ofpeduM das the lnfwmaAWx provided above Is
vue an/correct
Simatme Date. 1
Phone# -7'Z/ ^ �3 3
O,aicJd rca onl�t Da rat t►atar Gr tli4 once,m ben tosrpietad b!'cLry!orarusa oalc6i
City or Town: PermlMeense#
Ironing Authority(drde one):
1.Board of Health 2.Building Department 3.Chy/rowe Clerk 4.Electrical Impedor 3.Plumbing Inspector
6.Other
Contend Person: Phase#:
Information and,-
�n�tructions y
compensation for their�
Massachusets General chapter requiresall employers:coin� another under any contract of Lire,
pursuant to this smtnt0. an sarp/oyes is defined as"...araY Pews
C]W"or implicd,oral or wrIlIce
" armaship,associatiM corporation dr other legal entity,or any two or mine
An ssrplo w is defined as am isdividuai.p of a deceased employer,or ft
of the foregoing Maio int enterprise.and isclndmg 1� I loyee� Fbweyes 160
receiver or trustee of an individual,pa association err other In l cooly.employing emp ofIbiv
not more them three and who raided maeID,or the orb
owner of a dwelling house having m to do,maintensnu,construction or rep*WO .oa each dwcUft house
house of saaother who employs P be deemed to be an cmploya"
ord�grounds or building appurtenant
ihaeb shahs because of such employment
MGL chapter 152,125C(6)also stets that-every grate or loan Heeadog Wag shag withhold the Iuaanee or
rt sewal d a license or peamk to operate a bmdnm or to eoaMnd bull"in the emunwswedik for 20
evidem at Compliance with the assesses ewverags required-"
spptleatst who bar not Pradaeed aceeppbk >uor of id political subdivisions sbaII
Additiomny,MCI-chapter.l5Z:12SC(7)stags"Neither the�moam'� �
contract for the paknmanee ofpubtic work until acceptable c Maw of�>>�wuh the insurance
cola into any
rape of this chapter have been presorted to the oostraeft nthmM'
APPlleaats
Please fit out if
the worker'compensation affidavit comple*,by the boxes that aPPly b your stmatton amd,
iub,coubacoor(s)name(sI add"Kes)an0 phone nymber(s)aioegwith their = 9cat es)of
iaso •��d Liability CaWsaia(1•I•C)or lb*ed Liability P (I• M with no ea�loyea ot>ia than the
members or partners, are not rogoirod tD carry wo;kaa'cnaupemation If au LLC or LIB nee have
employees,a policy is required- Be advised that this a95davit,msy be submitted to the Department of Industrial
Amy cm*matk m of b manee covaagm Also bo tare to sign and date the afIIdavL 7hc afdavit should
b6 retuned to the city or town that the application for the P�or license ie being reqoated,sod the Depsrlmmt
of
Ind0Wd,Accidenti, MpW you have airy gatdtiom regardingthelair or if you are required to obtain a workers'
tthenumber*Acdbelow'. Self inroad should enter thus
wmPmeatioa pcholC;P..i' the D aion
self-iusmance Some numher an the
City or Tows Metals
sur hoe sine thus the aSidsvit is complete and printed le&1y. The Department bas Provided a spat at the bottom
please
of the affidavit t far You 0 0 out in the event duo Of cs of Investigations has to contact you regarding the applicant
please be sure to M in the pamW&cme number which wall be used as n reference nub
umber. In addition, aP
PHCW
that most submit nMultiple P BPP in any given Ym:>ICld only submit one affidavit indicating current
ref nation(ifnorpsary)aod,under"Job Site Address"the spphwm Should write"all locations in (city Of
town}a A Dopy Of1LE aigdavit Pod'basbeo OfAe t .>'srted by_t_he_city or town nary be provided to the
applicants proof that a va13d af9davit is ne 91e for share permit or licensca R A near atgdsvB bM b0 9lled out c2ch
year.Where a home owns or cith m is obtaining a licence b.comp I e this afBdavttbUSium Or OD�veamre
(ie a dog hicams or print to burn leaves ctc.)said person is
NOT repilld The Office of bvadgations would hlte to thank you in advance for your cooperation and should you bin any questions,
please do not besitats ro give ns a calla
The Department's addrCA telephone and firs nsmber:
The Commonwealth of Massachusetts
Depadment of instal Accident
OtBce of Invesdpdow
600 Washington Street
Boston,MA 02111
TeL #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM. MASSACI'IUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
9ALEM. MASSACNUSETTS 01970
STANLEY J. USOVICS, JR. TELEPHONE: 978.745-9095 EXT. 380
MAVOR FAX: 978-740.9844
Salem Butd_inn Deo��•++,•••
Debris Ebnwd Iyr
V—rm
In accordance with the provisions of MGL c40 S 549 a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
6 /n /l (Location of Facility)
ignature of Applicant
Date