25 ROSLYN ST - BUILDING INSPECTION (4) -PL*N6 Mg6T-9EflUES-AND APPROVED BY T44E
JUSPFXT.OR PWR TD.A.PERMIT J3fMG GRANTED
CITY OF SALEM
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' ate
No. D
Is Property Located in Location of
the Historic District? Yes No Building
Is Property Located in
the Conservation Area? Yes 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 Namee—
Address & Phone T/,,n
Architect's Name
Address & Phone L )
Mechanics Name �e-,l e / .-7 '
Address & Phone rT /1� 5?1- -/kz
What Is the purpose of buildirg?�� ✓f S ie.Q rr eoza l
Material of building? gv i o 6: If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cost 3 ,J_City License# N A State Ucwm b 2 ��
B� Laprovesiant X Lic. r _
na ure of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: J C) 3T L S
No.
APPLICATION FOR
PERMIT TO
e Nt
LOCATION
PERMIT G ANTE
AP ROVFD
S ECTOR OF B ILDINGS
4
t
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Board of Building Regulations and Standards
HOME IM,fR�OVEMENT CONTRACTOR
Registrations 103664
-"--9/2006.
'-t div idual
GEORGEL.GOO,Q - ' r
George GoodwlneN t�
38 Wabari St.
Saugus,MA 019n6 Administrator
�. tie �ioavmmaceo%DE o�,/uamac/rmeCk i
BOARD OF BUILDING REGULATIONS
ciIIN: CONSTRUCTION SUPERVISOR.
Numtlsr:;M\
021166
�� ' BIM¢uFs:0A73111�{7 !�
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Explrai¢#T21/20(i6' Tr.no: 19448
it
GEORGE L GOODWIN is 7
38 WABAN ST Y
SA US; MA 01906 �--C i lig C m4 nsr
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\ The Commonwealth of Massachusetts
Department of Industrial Accidents
'�� Otlhso/ImrostlDatlo.�nts
600 Washington Street, /h Floor
Boston,Mass. 02111
sty,.Workers' Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
a.
0
nam�ayI 4p .. . e!'H
address: e7S fl <),, p
city i/2f Arl state: i"// zip, phone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
Q—I-am an-employer providing-workers'—compensation-for my employees worki this fob
M t 4
'... ''.,� M .. .,. ' .,..
-77' x.r '7 'c'i''1 ia: a ''i 'y'da"^'SdT�*ek4..... t�, z¢�. sy r,•3 "Trrsky�.
address:' , .,
�y
t •¢ v� bx� �^4
city: _ nhnne Itr nk
insurance nallev M
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
Company name. -
address:
ct w r .
ins ran N4
&Qar4 .rx. `r ws,
Company name'. '
w t;'k" 'f 6•ryi Yt srn^SkrNM'1 IM,
address:
CITY' s r " . oilw; 't' l
y a,....
9 - t 4 ��,ff.A' qb .4•^4:4 b e ..,vo,.:ds.a �✓{'„Y,�71""' >
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a One up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of MOM a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby certify der the ins and penalties of per)ury that the information provided above is true and correct
Signature Date 24-k r
Print n e I Phone
0Metal use only do not write in this area to be completed by city or town official
city or town: permit/license#_[]Building Department
❑ ❑Licensing Board
check if immediate response is required
❑Selectmen's Office
contact person: hone a; ❑ffealth Department
comac
sere.Person:
P ❑Other
r
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 ajoint 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 ro—c-afhcensing aagency shairwithhold-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"la
w"or if
you are required to obtain a workers' compensation policy, please call the Department at the number listed below.
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 P ermNlicensember nu which wtll be used e n as a referencumber. 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.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
wee of lollesdgadsm
600 Washington Street,7&Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406
, t
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
}. SALEM, MA 01 970
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
ofBuilding-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 I50A.
The debris will be disposed of at: CU 1)7 GU044
Location of Facility
i tur of ermit Applicant Dat
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ltnd_rZc
Name of Pennit Applicant
Firm Name,if any
Address, City & St#fe
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.