5 ROOSEVELT RD - BUILDING INSPECTION (2) No Wkwft G~ Yak.,��p l�iLlai A CCU m
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OonNMaOn Awnt Yak.NO
BUILOW POW APPLICATION PDft
Parton ox
(CUala afthawr apply) PAM Rand kWM SWXY CW Mn& Dock. Shad• POOL
RapaklRaplaoa, oll
PLEASE FILL OUT LEOIELY a COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
Tha widwsoW hmW applaa for pemk to baud aowmft 10 00 tbwhp
owiara Name 6)/,1\f Rap /c
Addraaa& !/t/I 678` 7W - vo/
Arch sWS Name
Address a Pl aw (, I
Madw= Now ��1,�Jv/n �3 , lki -i 6, 75 )
Address a Phew ���/a/TLn� Jf�s4J1 yG73 j9�g1 77�t '33�3
wn,r r rr q.pooa ar armr� �(,P,D
wrww.i a a�rarq� r a dworM�,br now awry raa�s7 T__
wa armrp aaras a rw9
SAVA a coo aw uo • N A Orr uoww•
/ Us.
Nws " 07337
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103011 Soul) n of Mowwt
�-
:mm UNDER ns PENALTY
OF PMUXW
DESCewrwN oP wm To ea Dwa
al' Q k a rdd�-rj
Ma PEAMIT T0: �la;,h C
,�-sa o
No.
APPLICATION FOR
pP10110111 TO
LOCATION
PEFWT GRANTED 1
Id-/d T/as- t�
OF BUILDIPM
—\ Department of Industrid Accidents
Office of Ia+vra*atlons
600 WaslidnSWx Street
Boston,MA 02111
kv wwwnros pWas
WorkeW Compenaadon Insurance AfWavit: BUg&MContrsdorsMecMd�umbers
A n In Plisse Print L ZO&
Name l
Aekbress
c;ty�s,al Jar r�u�as _ peane :. 9�d - L/-33 33
[2.
re as&n employeet CheektkeWMrlatebow Type dprof(rod'em:
I.V i a employer with -3 4. I am a SNWA contractor and I 6. ON
�,�N c'on`a.-lc-ndion
employees(bill anw err past-time).' bave hued doe mb 4onaaetu:a 7. L�
0 1 am a sole proprietor or parmea lesion oa the artraclo abut= 8. ❑ Demolition
These sob-aoanactors have
ship and have m=VIW a werkwoomp. immy 0 Building addition
wv rdo forme in My Capacity
CNo �, I S. ❑ we are a corporation aid is 10.0 Electrical repairs or addition;
officers bow a msW rhea en adelitiom
3.[] II icgo aahoIDeowna doing all work right of exemption per MGL 11.0 Pbnnbiog r ptu;
myw
o wane s' comp W a 152,41(4),and we have no 12.0 Roof repab
insuraoa taNved I t employes [No wolkaW 13.0 Other
com*insurance raauhv&
•AaY NV> drrt c3ecblwc g wo etw finuutew nWm bebw ioMina dfeir wo,bn'w�mra&m PoeaY ie6a .
f rbmeowvae tiko VAIM,dde am&*bw&mft dry ado"on wak and dim ton wade eo newt whoa a row ds&vb b&min;sack
:Cwtmclwe cheek 16blwa rout Ateekad m a lado w cheat&owma 66 nor of dw and dwir"&w owp PAW
wbrnwsm
!.w a eetiploya rh&r is provldlrei
workers'eewpe&srdon tesnr&net fsr MY satploym Below b ibi pottq end job sbe'
Imma=Compmyl4#='
policy p or Self-ins.Lea
Expiration Data
robsinAddrers: has �n vo l� ,P�/ ' city/Stateft:
Attack a eopf of the worMW,eompeondes polky dedara dw pals(shoeing the poky number acid eq&"ion date}
Far'bne to secureCo�as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a
floe up to$1,500.00 and/or one-yen in priscma at well as&a pe;alde&in as form of a STOP WORK ORDER and a fins
of up to$250.00 a day against the violator. Be advised that a Copy of this Statement may be forwarded to dt Office of
I..d *m of the DIA far ice coverage verification.
I!o hereby«roe under Ae pates and p xdAn of per/wr Am tk*Wwwadon pwlJael&bow v aw end core"
/z1 27 M S--
O,flrv!rw Do&de errdar tr rhtr erre.b b+mwpfirel by eby ermaw o,8letd
City or Towns rermM/IJ«arm M
Inong Authority(circle one):
1.Board of Sean 2.BuUding Department 3.Catyfrown Clerk 4.Mectrcal Inspector S.numbing Inspector
6.Odwr
Contact Person Phone il:
Massachusetts Gearal Laws chapter 152 requires all employers to provide wortas' compensation for then emtployens.
Pursuant to this statute, an ewploym is dcfmad as"...every person in the service of another under any contact of I M
express or imphe4 oral of wastes"
An agpispe►is defined as"an bdivi&A pwaga tp.anoakdOI6 aorpaatsa or other ftd entity,or any two or more
of the foredoiag aped f l a joint atapria;and mch►dio fi the legal rgmc mdm of a deceased erployer,or this
receiver or.trsgea of,t.iudiva"pwmad*association or other W entity,employing employees. Htrweve r the
owner of a dwelling house having not muse tuts three sparbmat and who resides dtercm.of the of the
dweniog house of another who employa persons ado mamma w%contraction air repair wok a such dweltiog Lome
or on the grounds atbuilding appmtensel thereto shall rot because of sock employment be deemed is be au employer."
MGL chapter 15X 12SC(6)aloe states that"every state err local ken ft apuq dud wkhhdd the!nuance or
renewal of a tleetne or pert to operate a bus mn or to construct bWbBmp in the eomasooweakh fear sup
appmean/wbo bra not produced acceptable evidence deomplism with im bas rases eerverap requresese&"
Additionally,m%c'h eonttactapeer 152,12XM stales"Neillaw the commonweal®nor any of it political abdivitiona shall
ester bolo say in the perhimaoee ofpublic wort uMB acceptable evidence of empliaooe with dw:instance
regairamata of tbii chapter bane bem presaged a the eoutractiog anthe®ty."
Applicants
Please fin out the workers'wmpwadoa affidavit completely,by chwag the boxes that apply b your ahead=sod,if
secmaay,apply mh-000aow*)named addreas(es)and phone mmba(s)along widt their cati9cate(s)of
mma ace,.Limited Liability Compass(LI.C)or Limited thbrity Parmersbga(LLP)with no ea loyees other this the
members or partners,we not required go cagy wwkeW oompasstim imoraoos. If an LLC or LLP don have
employees,a policy it required. Be advised thu this affidavit may be submitted to the Dgwmuat of Industrial
Accident for cenfLmation of hourance coverage. Aber be sure to sip and due the aflldsvL The aSfdsvit should
be returned a the city or town do the ippliation for the permit or liceme is being requested,nest the Departme m of
Industrial Am*mL Should you bave any questions regarding the law or ifyou are required m obtain a workerst
compensation policy:pkabe call the Department at the number listed below Self-immed companies should eater their
seHisstaasce fieeme nmiba oa the is I I lab.
Mar Toth OI>ldaN
Please be sure do the affidavit is oomph oe and printed lc&ly. The Department bas.provided a space at the bottom
of the affidavit for yoo to fin out in the event the Office of Investigations bas to contact you regardfrtg the applicant
Please be sure to 1111 in the.parnki ems trnmI which will be used m a reference number. In addition,m applicant
that must aubim multiple pamWhcense appliMmus a any give year,need only mdnM one at8davit indicating cturent
policy ioformation(if wcmuy)and coda"Job site Aadrese^the applicant should write"all locations in (ciW or
towo}"A copy of the affidavit dot has bees otlkWIy smnpcd oz,marted by the,city or town try be provided to the
appliam as proof that a valid affidavit is m fib for&we pert or licwes. A new afWavit host be filled oat each
year.Where a bome owns or dd=is obbinios a He me or permit not related a any bushain or commercial va u e
(ic a dog hceate a peimu to buin leaves cIL)said person is NOT required a c=Vkw this affidavit
The Office of Investigations would bike to thank you in advance for your cooperation and should you bane any questions,
please do sot fames b'givem s call.
The Departments addnas,telephone and flu number
The Commonwealth of Massachnsetta
Depattiment of Industrial Accidents
COMM of InvestlPtIon
600 Washington Street
Bostao,MA 02111
TeL #617-7274900 eat 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2"5 wwmm.gov/&
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
a
R
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildin¢ 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:
(Location of Facility)
ti
_ZaAAVJ
Signature of Applicant
Date
B. F. Murphy Plbg.& Htg. Inc
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
�5_(T err-1 (J .Mass. Dab I vJ 79_ PermiiA
Building Location 205 sQ,Yri Owners Name V;Qr-'j__L
Map: Lot: Zone: Type of Occupancy
New ❑ Renovation ❑- Replacement ❑ Plans Submitted: Yes❑ No ❑
FIXTURES
Fee:
Y q z
q 2 Y
j O1 F j fI!
N 0 2 w w
W Y J q O < q 2 O g R Q
a1 2 ar < 6 < F 2
O W
N O 2
D 2 e' m q W < F a1 = O < g O 6 6 R O LL
. ¢ W 0 F W < q O < J q ¢ R J O W O LL 6
< ~ Q < S g q Q < O < J J < 6 C 6 < O < F
'= Y J O1 g O J O 31 2 F q LL O J o < 3 ¢ at 0
SUB-BSra T.
BASEMENT
1ST FLOOR
2NO FLOOR
9RD FLOOR
aTH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR ##
6TH FLOOR
Instelung Company Name B.F. Murphy Plumbing &Heating Inc. Checkone: Certificate
Address 72 Holten St Danvers, MA.01923 ❑ Corporation
Estimate Value of Work: ❑ Partnership
Business Telephone 978-774-3174 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Brian F. Murphy
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which mats the requirements of MGL Ch. 142.
yes ❑ No ❑
If you have checked M,please Indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:_I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass.General Laws, ands that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent❑
Signature of Owner or Ownar's Agent
I hereby certify that all of the details and information I have submitted(or entered)In above application are true and acarate to the best of
my knowledge and that all plumbing work and installations performed under the permit Issued for this applicallon will be in compliance with
all pertinent provisions of the Massachusetts State Plumbing de�r 142 of the General -
By
Signature of Licensed Plumber
Tile
Type of License: Master A Journeyman ❑
City I Town
APPROVED OFFICE USE ONLY) License Number 9325
PwncaE a2)R2
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES _ _ PROGRESS INSPECTION '
FEE .:
APPLICATION FOR PERMIT TO DO GASFITTING
NAME& TYPE OF BUILDING:
LOCATION OF BUILDING. .
.. - PLUMBER OR GASFITTER
LIG NO. -
. _ PERMIT GRANTED
..DATE .Tg-
GAS INSPECTOR .. -