72A PROCTOR ST - BUILDING INSPECTION fL-N61 Wr-gEfogE94ND APPROVED BY T44E
mzPj=W PRIOR TD APEW AEING GRANTED
CITY OF_SALEM
No._ j/ - �� \ haw I 0
Is Pmpwty Locand in Location of
aw Nwodo ow"? Yam No sasiasns )l /P m
Is Rapwty Located in
to corwwvat on Ana? Ya—No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof roof.Install Siding, ConstW DO*- Shed, Pool,
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
Owner's Name Btu u-n � no 72
Address & Phone 72 Nn I�yj Sf Don Vi5 mg
Architect's Name
Address A Phone j 1
Mechanics Name
Address & Phone / l
Whn is aw p xpm a btr ft?X I fc-
WNW of bull "? V wz) 0 a dwat Q.for how ma--n//y two"? '
will b A*q corMoml to Iaw? //� Aabaata? fYO
CS
EslYaatad cat /S 00 0 my liartaa r N A sal iartsa r 07337E
Ram. ��-•••at
tit
Lie. f `
S' to of Applicant
D UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO. 72T/d Ad1 �J ��1/l l I/�f� (//�fi ��I
No. 2U
APPLICATION FOR
PERWT TO
LOCATION
PERMIT GRANTED
APPAOV�D
7
OR OF BUI NGS
j
y� The Commonwealth of Massachusetts
-\ Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
WHO.mass,gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contrrctors/Eleclea Print nt Legibly
umbers
Please n
Applicant Information
Name (gt prganization/Indlvidtu`0:
Address 4 Yl St
City/Statemp:
�hv ,u/ vt. VI), _ Phone#:
A
reployer?Check the appropriate box: Type of prated(required):
I. ployer with 4. ❑ I am a general contractor and I 6, ❑New construction
employees(full and/or part-time)-* have hired the sub-coutractm 7. IZ'Remodeling
listed on the attached sleet t
le proprietor or partner- These sub-coutraCINS have 8. Q Demolition
have W employees workers' comp.insurance. 9. Q Building addition
for me in any capacity.
5• ❑ We are a corporation and its
in3m.'sna 10.❑ Electrical repairs or additions
[No workers' comp.
required.] officers have exercised their
right of exemption per MGL I I. Plumbing repairs or additions
3.❑ I am a homeowner doing all worI.[]
myself. [No workers' comp. a plo ees- [ and or have no 12.0 Roof repass
employees- o workets'
insurance required•]t cow yinsurannce required.), 13.0 Other
'Any applicml the checks box#1 nwo also fill art the eechon below ebowmg timtr wmlms'eotnpmeaWm Policy mfornmbon: .
t Homeowvers who submit this etMovit indicating they are doses all work and then here outside oontred ffi
ors must subnut a new affidavit indicating such
tCootrwwee ttmt check t box mu
his st atteched an additional sheet sbowm o g the none of the sub•mntradors and Ow wo&M,comp.Policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the poliky and Job site
Information,
Insurance Company Name:
Policy#or Self-ins.Lio.#: Expiration Date:
Job Site Address: la B 1 l D7Jl n' 11 City/Stawaip: J Lt tr
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Pagure to segue 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 verifwadm
I do hereby ce r the pains and penalties of Pedury that the infwmadon provided lbove P true and correcit
DatPI e: dd�
ne#: 3333
Offlelal use onlys Do nat writ in fhb area,to be completed by e4 artown gakid
City or Town: Permit/Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
11liVl lliN6lVii Nllu i1L1A 61 1a�.61V11►7
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 wriden."
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)muse 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,§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(w)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 affidaviL 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 licensemumber on the appropriate line.
City or Towv 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 permit/license number which will be used as a reference number. In addition,an applicant
that roust submit multiple permit/license applications in any given year,aced only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"The applicam 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 Me for future permits or licenses. A new affidavit must be filled out each
year.Where a bome 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#617-727-7749
Revised 5-2fao5 www.mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
3 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, 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:
il
/ / w (Location of Facility) L�
v
Signature of Appl an
IV
Date
BRtQW 'S K fTCHEN & BATH CENTER .
15 Elm Street • Danvers,AM 01923-2058
Mailing address: 72 Holten Street ` Danvers,MA 01923
Telephone(978)`7744333 Fax(978) 774-8709
Home Improvement License-#103611 ! -Mdss:Builders License+#073375
CONTRACT
Tbiscontl0ct,dated below,W rusteriels"or labor to:be wopfied by Browns Khotieq&Bath..center
Mereimfter;referred to as the:eontractor),at the sole requesfand order of
NAME:Joan rioddard PHONE: 978-745-6416 DATED July 28i3005
ADDIZESS::73A Proctor Street,Salem,MA10100
silos
(HatWafterreferte*.i stheownerorbuyer);tobesopphc&perfwMWstwentisessetforth above;,subjed,toelt:ofthetemiaeud
condition set forth op Pf fba Ag:ecmgg,as fallow s
._:.
Browns Xitchep e4 Bath CWd"p1o&WdW fkmhh'you wilka quotation on your%itchen remodelltrg.
For theptirpase afthis quoteW&Mie used Tedd Wood custom cabinets. These would be supplied and ingalled
according to ow•design and drawing.Door style;hardware;woods species and staimcolor are tote decided
Chdin8td 60 Pr a4e,& 619/41 - ChurRy=Ct�trrrtd' jetlntof 0- t- Aoer
Beetke:The floor-,ili bepreparedfowhryk S�Q
last None-
Plumbing;Xe will disconnect and recormect,appliamoes: n li bD u2 a-C}4,1.p� G
Wewill supply and inuai m sander mount stabdesssteekstnkU h by:E (k wit -a KohlerCerltsfaucet
We will comsect owner supplied disposal and dishwasher.. y p�
All work to ber connected to eatisting plumbing.(f any upgradesare needed a quote will be provided
Ventilation Noge,
Heatkre;None
:,Nape
QZMUL Fot this quote Mid-- fd F,", ica with go baekspfash has been quoted (Some Corian:colours are
hi her m rice 77ne walls between the base turd cab have an owner 8 P ) upper frets ,r lied tife9rawtrs i tolled. . ..
uPP nS
AnnNonces, Set&Level No assemb(m ofAMces
`Counj t�s are trr(ced trey our measrsremenm size changes will affect duke,M{rrble like the is an added coat for
instgil n Tile bafksalpsi�q are nuked[or InstoKadon ofa plain sbaleht backsnlashes InMcatgg tterns are
an additional cost for Installation.
lip
Nothiag atherfltax stated above h included In this quote No paint or paper.All sales tax is included AU
necessary permfls have been Included All work li fidly bisured Any debris created by Browns will be disposed of
by Brownsl.
R isunder400d and agreed that this eardrect will be coWleted on ar:Wors the day of 20ol. Tu,autvar
ropments nod warrants that he is owner of aforesaid W=6;and that haWw has read this a)peemant set forth on both sides.
11 IS EXPRESSLY AGREED THAT NO STATEbIEItT,ARRANGEIff OR UNDERSTANDING,ORAL OR WRITTEN,
EXRE9SSb h$E�lp11Ep JOT CONTAIIVED HEREIN q II L BE RECOGNIZED ifND THIS`CONTRACT CONSTITUTES THE
ENTIRE XGREEINENF.`", .,
R is-farther agreed tbat ibis arourad is notsubjgot tocaoallation a crept by w-dttm.consent of both parties.
SALESPERSON: ACCEPTED;
ACC EPTEb BY:
X
Xf
(SUMCT! Tt7 ►LL C1y THE REVERSE SIDE).
✓/vBOARD� RE ULAATIONS
OF
`.LIcMN• CONSTRUCTION.BUPERVISOR d
llunWr Cq11 073375'
BIU1MtF 091p3(1952
, E�iris, 200g.. Tr.no 2575.0
r
00
�; •BRIAN F MURPW i{
�OANNVERMSS, MA ssioner '