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12 1-2 OSBORNE ST - BUILDING INSPECTION No. _�� APPLICATION FOR PERMT TO LOCATION 05601'nc PERMIT GRANTED Sf I�A 19 7 u7V`D INSPECTION'OF MJILDM r gPWO WIDE filA941019 APPROVED 9Y R E CITY OF SALEM Il Dr.A. VJ J Word �� ... ZOr*VabM Is PMPW"LWOW In Location f1N... .R .o oiltdw YM No_ of Is P WNY LOMM In ConowvMm ArW YN No v\ Permit to: BUILDING PERMR APPLICATM POlk (Ckde WWI*~apply) Root. Reraot, Install SO4 CMGUW Oadr, Shed. Pool. Rspak/Replaoe, olll.r: PLEASE PILL OUT LEGIBLY a COYPLEn LY TO AVOID DELAYS N PROCESSM TO THE INSPECTOR OF BUILDINGS:The undwsiWod '. hereby applim for a permit to build as offt.to the toNowkp Owner's Name Addmu a Phone Amhkeds Name Address a Phone I 1 Mespanin Name A/?Se& AvZ 561VS C'QN7-Z1qcr/ivy �/VC . Addreaa a Phan. 97,F — 7yY- %a6 c97p, - S�y—���� WIN!Is n0 prpoa it bul W wwl a b1�IgY N a dwslYq,for how miry tnnels?--J, ,� VWbj"V rw m 10WO Mbs"? E.rin.l.s co!!G�\ \�1��L. - aw.Llo.r.• /h �,��3 S Oman Lie. Il� SW&Wm of AppYc m SIW= INrDER THE PENALTY, DESCRIPTION OP WORK TO BE DONE OF PL%RMY L11A S /o//y-6i MAIL PERMIT TO: ueparrmenr of inaasum Acctaenta Office Of IXWWS4&xs 600 Wasidngtoa Strut Boston,MA 02111 www.asasa:godd it Workers'Compensation Insurance Affidavit: BnOders/Contractors/Eledrkiaalsi?lnmbers Applicant Information Please Print Lesibly Name Address: City/State/zip: Phone A Are you u employer?Cheek the appropriate box: Type of project(rcgtlred): 1.Cl I am a employer with 4. ❑ I am a goad conewim,and I have hired the sub-contrac tort 6 [--]New construction 2.❑ employees �le(proprietor of Partna- listed on the attached sheet i 7. ❑ Remodeling ship and have no employees These sub-mntraaors have S. ❑ Demolition working forme in any capacity. workers'comp.iosma g. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical or additions 3.❑ Ir am a�hom off an have exercised their eowner doing all work right of exemption pa MGL 11.❑ Plumbing repass or additions mysd£[No woskm' comp. c. 15Z)1(41 and we have no 12.0 RoofrgWn insuraee requked I f employees. [No workers' 13.❑ Other comp.insurancerequirc&I 'Any applicant�chedn book 01 Mier dw fill out the notion below thow�their wmbn'ampmrdo.Doti;;belbrmatlomL t Hon eownae who submit this SWAkvit Re iatiot they are dams all work end dim hoe autdde coobedurs most submit a am affadevit indicating such. iContreclom list check Me lank mta nhebed an okVioosl shed sbowica the come of the eeb-c don and d war woems•ownP pdloyvd'ormetlon• I am ase employer that b providins xvrkers'eompemation ftmmnee for my employeea. Below a&epolhry and job she inf Insurance Company Name: Policy All or Self ins.Lit M Expiration Date: Job Site Address: City/Statrizip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Fail=to segue coverage as required under Section 25A of MGL a 152 can lead to the imposition of aiminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a flue of up to$250.00 a day against the violator. Be advised that a copy of this statement may be f awarded to the Office of Investigations of the DIA for insurance coverage verification. I6 ksniyee��/�Simm= anJpe(/�titan y6e Grjorawdoar provilel closers a bus a+rd eon+rat �' `// Dom. Phone 4: Offleid we only. Do nd write i e dab any to be completed By cloy or mwa o fIea1 City or Town: Permit/I.tame s Issuing Authority(cirde one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Eleetrkai inspector S.Plumbing Inspector 6.Other Contact Person: x{ Phone N: thm JOYGM Massachusetts General Laws chapter 152 requires all employes to provide workers' a for contract ct o fbit% Pursuant tn this statute, an,mplayas>s defined a"...every person in the service of another under any contract of Lire, express or implied,oral or wrilms indiv An u+ePmYp it defined an an idual,parm aershrp, MdOian.corPtratian or other legal entity,or my two or mote - oil including&a legal rVresematrva of a deceased e�loyt=-or this of the foregoing c gpgcd in receiver oc trustee of an iadia joint vedoal.parmershtp,awctatrou or other legal emity,employing emPloYap Howeverthe owner of a dwelling house wing not more than throe Munnem✓e and who maids&acie,or the OCCOPM _ dwelling house of another who employs Persons to do maintenance,constriction or tepee be deemed to be an employer" or on the grounds or buildingsppuricasin Ihaeb shaD net because such employment MGL chapter I52,12SC(6)also sue+dust"every stile or local Beensint age«9 stag w the laws or renewal of a license or permit to operate a business or to eomtruet buildings'atic comranwealth forr any apptleaat who has not produced acceptable evidence of Compliance whb the insurance eoverage regvr»_ Additionally,MGL chapterf 152,425C(7)etsf a pubhe wodt untilNeither die acceptable aide=of compliance mmonwcaft a"any of"I POS" mms> ranee enter into any contract t t e Pa n ee requirements of this chap to rho wnstactiog suthgrity." App§cmb situationand,if Please fill out the workers'compensation afidsvit�p�y,by checking the boxes that apply to Your s)namc(s�addraen(a)and phone mm�ba($)along with their calf ieatie(s)of ' it d Liali Con snip or Limited Liability Partnerships(Id.P)with no employees other than rho insurance.,s parme Liability Comp m��,en If an LLC or LLP does have mambas or policy i are not required a cart employees,s policy is requucd Bee advised that this affidavit may be submitted to the Departrnmt of Industrial Arts IN ccn&manon of insurance coverage. Also be sore to sign and date the allldavIL � thoufld be returned to the city or,town that the application for the permit license �not b chimer a workers'DeParutie industrial Accidents- Should you have any gaptrona regarding should enter then compensatimpolicY+please the mimba lusted below. Self insured companies self-insurance tleense norubt'i on the unit City or Town OAldals is lea and printed legibly. The Department has provided a ePace at the bottom Please be aura that the afidavit ooaup of the affidavit for you to fill out in the event the Office of lnvpdptions has to contact you regarding the app Please be sure to fill in the pamwhccme number wbich well be used a a reference member. In addition,an applicant that must submit multiple permit/hcense 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 bcations in (city or town}"A copy of the atBdsvit that has been officially stamped or marked by the city or town may be provided to the applicant a proof that a valid affidavit is on file for fidtre permits or liccnm A new affidavit must be filled out each yen.VIbere a borne owner q citizen is obtaining a license or permit not related to any businessor co»rcrcisl venum (i.e.a dog license or permit to bum leaves etc.)said pason is NOT required In complete this a8idsvk The ot8ce of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate t4 give us a cad The Department's address,telephone and fa armba The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiptions, 600 Washington Street Bo"MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwwmass.gov/dia a BOARD OF BUILDING REGULATIONS . fff ` 'Llcetm CCONST RUC TION SUPERVISOR I" 1` Number 0 OB6835 � I 1b08 Tr.no: 8863 ~;ROBERTK^ARSr ,Al CEDAR ST SALEM,'MA 01970 ti I° Commbalf.', Sa.... :Board of llutidfogRegulations and Standards, �' = NOMEIMPROVEMENTCONTRACTOR I Re�iabt n_jd"gl878 l" � �o°corporationCTING INC.Si� O AI' c , �. SALEM,M-Ai6l0 Administrator -, CITY OR SALZM9 MASSACHUSCTTS PUaUC PRO►ERW 0E►ARTMENT r 120 W"HINOTON aTRKW, 340/LOOM ' sALaM.MA 0 i S70 TaL (970)7/8-nn CV. 300 Is FAa (e76) 740.9" l STANLiCT A Usovics. AL MAYOR DISPOM OF DEBUTS AFFIDAVIT la a000sdaaa wish the provisim of MOL a 44 m4.I selmowWp that e a eaoditim P # all otH� dshria e+aatNioS iilom the oaaeemctioat ' pvamed by d6 Pemsit shalt be dirpond Otis a properly Helm"solid-vmm disponl lhcitity.ar defined by MM a ID.SIX& 'Ile debris will be dispaed otat: LocWw GfFiWW ip ones of Permit Applicant FULLY complate the fol3owng information; (PL11E''ASE P 1RINr CLEARLY) ) PL f Name ofPermit Applied Fnm Nus%ifxiy i 2-k l y o p Address.City R State Tbs above Statute require that debris hnm the demolition,reaovgwo,rdtab a o(her altaSdon of building or ss wun be disposed io a priapaly-liceaaed soh&wla disposal ficility as defined by MOL clA S I SOA, and the bwldiq pamite or license are to indiate the beadoo of the facuty. UepanMeM of inartsrna AlMaenrs 0,f4er Oflnvesefgations 600 Washington Sheet Boston,MA 02111 rvlvsscntassg0Wdb Workers'Compensation Instinct Affidavit: Builders!Contractors/ElectridansMnmbers Applicant Information �I Please Print Leeibly 4 Name 1e5�.4-1/16 !' �SaivS Cori ANC'• Address: VZ OhD 42 S T City/Stat Mp: S .4 Z.e&, iY1.sk , y�990 Phone A 9 7fi- �yy-,9oa o Are Y�n empbyer?Cheek the appropriate bm- Type of project(required):1.Fl am a employer with 12 4. ❑ I am a Bengal aonescomr and I employees(Sin and/or part-time}' have hired the sub-cmdrat km 6. ❑New constrocdon 2.❑ I am a sole proprietor or Parma- NOW on the attached sheet= 7. 0Remodelini ship and have no employees These sub-contractors;ban S. ❑ Demolidon working for me in any capacity. woders,comp.lnaar8ffie. 9. 0 Buttldmg addition [No worlaiso'comp,insrance S. ❑ We are a corporation and its r offices have exercised their 10.❑ Electrical repairs or additions 3.❑ I� homeowner doing an work right of exemption per MGL 11.0 Ph mbinB repairs or additions myself[No workers'comp• a 15%41(41 and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.0 Other comp.insurance required.] •Any applir�t Pot d mb bon 01 mot also 6n out ma section below tll"An em*workers'motion policy mformadoa t Homeowners who submit min aAidevit iodintioa dory an don ell work and teen bue outode 000Reaon eeaa aft*a om @M&vlt let ieating such tContracion ma check fin box need atechod an additional sheet sbow•ioa to sand of me sub•coft inn and Brit%v*W cony.ply utfonete doe. Ian m employer dot is proviAng workers'compensatios Grsarnce fer my employees lldow br d wpolksy end job slat Insurance CampatyName 7 QA u L 7fZUf L L7ZS Policy#or Self-ins.Lic. # 9 9g(01A Expiration Date: 07 S Job SiteAddren: %z /V OS6Uvl?iVh' S City/Statcq* S /nPh. !1 4 elf 7o Attach a copy of the worken'compensation policy declaration page(showing the policy number and espbrat3ou date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criazinai penalties of a fine up to S 1,500.00 rod/or ono-year imprisoome�err wen 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 Imadgations of the DIA for insurance coverage verification. I As Awrebyce►o wader dkapolarr anlpenable ofperJnry am tke ktfwmadex provided above Is&w and cornet Sinamre d� l Dace- 7/s o 0 Ojkk i we only. Do no wrbe GS tM area,to be completed by dry or duos odleld City or Town: PermMtuftese# Inning Autborny(circle one): 1.Board of Ban 2.Building Department 3.Cityfrows Clerk 4.Electrical Inspector S.Plumbing Inspector 6 Other Contact Person: Phone#• Massachusens General Laws chapter 152 requires all emplOYors 10 Provide workers' sensation for ilia e,nptoyeo. >s defined as"...every person in the service of another under any contract of Lim, pursuant to this statu0e, an nreploye�s . errpros or implied.oral or writoen adity,Of any An earpfoyer is defined as"an individual,partnership,assaaatu.oorporatian°r d of a decea6ad empbYtwo Or Oror tie more of the forcpiog engsgcd in s Joint mtaptiw,and iuchidmg the'W' n'reroen>at recetva or Unsnae Of an individual.parmersb*association or other legal enfitY.=Vloft emPlOYaa however the Owner of s dweDog house having not mom than three and who resides therein,Or the WMPW of th s ow Owner o house of amiothes who employs persons b do maintenance,consouction err repair worlr on sac,dwelling�� or on&c grounds or burls ft tberew abaD tmot beeatise of arch empbytaentbe de ended b be an ernpbya." MGL chapter 152,125C(6)also stato that"every AM gr local 8cendng ageacy sW wkbbold the Inusoee or renewal d a litchis or permit to operate a btidnos or to construct buudngs In As commmwnkh for sty who hag not produced acceptable Witless d compfiauee wit,the hfn cover" roquirud s,aII APPRUM Additionally,MGL chaptsx.152,125C(7)awn"Neither the co>t�ealth,tor MY of illpOWW wbdivisio cuter into say contract is the perfmmance of public wodt until acceptable evidence of compliance wi*die insurance requirements of this chapter have been presented m the utsac&g an1)wntY• APpilemb fill the workers'cm�sstion afgdsvd completely,by bones that apply ti your situation and,if Please necessary,supply�ntrac0*0 RMCON addu(es)and phone number(s)along with tick ealificate(g)of ,an = . Limited Liability C=Wnla(LLC)or Lanad Liability ftft ship(1dP)with no employees other than the members or partners,are not rgpimd 10 MY workers' oompeosasion iuggr . If an U C or UP does have =Vjoy ceg,a policy is required. Ije advised that d s uWavit may be submitted to the Department Of Inda3o'al Accidents for c�tinn of innnanee txrverage Also be anre to dp aced date the affidavit. tslioald of be returned b the city Or town that the application for t,dpermk or license is being re9acstnd+ not ft Industrial Accidents. Should you have any questions repM*the law or if you am required tr obtain a worlcets' compcnsadm Policy,pig call the Deparnt at tltc mrnba Laud below. Self itiaured Oompmaia should eats thek self insurance Ikense 6wim on the liner City or Town Officials Please be slue that the affidavit is complene and printed legibly. The Department has provided a space at the bot0om 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 pamW.ieense tuba which will be used as a reference comber. In addition,an applicant that mist submit multiple perm vimnse applications m any Buie°year,need only submit one affidavit indicating current policy mformauon(if necessary)and under"Job Site Address"die applicant should wale"all locations m (City or town)."A copy of the affidavit that has been officially clamped or marred by the city'or town my be provided to the applicant as proof that a valid affidavit is on fie ins Mum permits or liceases. A new affidavit mast be tfiled out each year.Where a home owner g(cid=is obtaining a licenae or permit not related to any business or commercial venture (ice a dog license or PomIIL b bum leaves ere.)said person is NOT required to compels this affidavit The Office of investigations would hlte to thank you in advance for your cooperation and should you have any questions, please do notbeaitO to give ns a cell. The Departments address,telephone and&a number The Commonwealth of Massachusetts Department of lndusbial Accidetlts OtAce of Investigations 600 Washington Stt d Bo"MA 02111 Tel. #617-727-4900 ext 406 of 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass-gov/dia 43 e . . .. Bedroom#4 Smoke Detector Layout pr � rDi=A+�/lam/�},r 12/12-14 Osbome Street Salem,MA 01970 $ukded @wCv"d.3.LTJ 8':;,y Ca..:L''�P authc*ltj.Jm.vj—!-g.-' z ;i=aa. FIRE PRZWMI ZL411 ZT EZ U Mk, BY PLARSAREAPPRO�'ED SDLLLV rDR tL` F'1`t-' '.T! ' ' TfPE AT?D.LQPtFT*N OF-FIRE P,LL FIRF',PROTECTlOR.DFV{CE3 SRC V'''F1�.CY i� A EIkALTL�STJL".!'�dM3PF.GT'14Rr COR CObtPL,T."..'y ,PAM WIiM THE FIRE COPE. r Bedroom#1 Bedroom kitchen Living room i { Dining room o � o Smoke Detector Layout 12/12-14 Osborne Streel Salem,MA 01970 5 Dining moM Living room Bedroom#1 ° e a hen 20 r Bedroom#2 Bathroom d Smoke Detector Layout 12/12-14 Osborne Street Salem,MA 01970 i HW e HW { � o Smoke Detector Layout 12/12-14 Osborne Street Salem,MA 01970