26 PERKINS ST - BUILDING INSPECTION -11IL-01146 1006TaE-F&&� AfkPROVED BY T44E
JdSPFCIDB pRW TD A:PE UXT AE1NG GRANTED
�ll '\\ CITY OF SALEM �}
No�/�=V� i Date 0 �5
Is Property located In f Location of nn
the Historic District? Yee_No_ Building �lD VF.2/11.y3 57-
la Property t ocatad in
Nw Cmaervation Anna? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:Siding,
Of exolntFT
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:
Owners Name PiCN,-20
Address & Phone U KI k�rU D2i yG & Lw Nq. (617 ) 46�4�"
Architect's Name /xXGme
Address & Phone A/.
Mechanics Name a aa/ 9f//<p//V
Address & Phone RY0h/7¢�yirGrnk,.�lr1 (�/ ) &'6///36
What is the purpose of building?
WWW of bulldirq? tV0 v/D N a dwelift, for how many families?
WIN WNW corriomt to law? Asbestos?
EsfYnated cost City license e N p' sta e / o
Baste Improvement r/ a
Lie. I
Signature of Ap ) ant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
r
MAIL PERMIT TO:
Iv
M
t�l� �S Na�.L1.�LJ
APPLICATION FOR
PEFUT TO
LO/CATION.//
PERMIT GRANTED
. 3
A tPR,00V�D
INSPECTO OF BUILDINGS
9
F o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
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 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 III, S 150A.
The debris will be disposed of at:
Location of Facility
' Signature of P Applicant D to
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
a Aft /7 fX//y_Grlw,( // - da�0
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.
Tire Commonwealth ofMassachuseus
Department of Industrial Accidents
office 811fiveseadm
600 Washington Street, 70 Floor
Boston,Mass. 02111
rs'Co surance Affidavit: Bui al Contractors
(?1em,7,ee2 )?'Pinaill"la
address, 5 11(1A((17;Vvfa1,f
city &Oz!�-74e—o state: YA 2ip� 017*-30 phone#617-46,9-4,P,0
work site loc ation(NII address):
E) I am a homeowner performing all work myself Project Type: [I New ConstructionE]Remodel
I am a sole gr rietor and have no one worki capacity. E3Building Addition
1 am an employer providing workers' compensation for my employees working on this job.
Rome. 4
V,
gildresur
citv: 1-iln
I am a sole proprietor,general contractor,fr homeo-wWi�Kcircle one)and have hired the contractors listed below who have
the following workers'compensation polices:
COMPBRyname.* ee�X&l
address: P, 0,156,X 1;7,0
7
A/xi- u4q2rl
obang#
D hii i
WI
"A
company name.
�4, 777777777,
address,
e
4
Failure to more coverage a required under Section 25A ofMGL 152"a Ind to the imposition of criminal penalties art,fine up to$1,50(1.00 and/or
one years'Imprisonment a well as civil penalties In the form ors STOP WORK ORDER and a fine ofS100.D0 a day against me. I understand that a
copy or this statement may be forwarded to the Office of Investigations of the DIA for coverage werification.
I do hereb cer er thepains andpenalties ofperju P 'd d above' It and orre
ry h
Signature The"Orn"'on"' e Date 's.5ru)?A
Print n a me Phone#..... 617- WK MCZ
Official use only do not write in this area to be completed by city or Iowa official
city or town: permit/license#_[]Building Department
[3LIcensing Board
check if immediate response is required ElSelectmen's Offtce
[311calth Department
contact person: phoueN; —00ther
S�p 2(X)3)
1
v
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 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 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 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, 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
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.
�x
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 number. 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.
LL
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
emes tlUnOsd aden
600 Washington Street,7'"Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406