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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 �` �� ' 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 _ z 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 !� �E 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 - z \ 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.