18 SETTLERS WAY - BUILDING INSPECTION a
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T 16'WT-BE fiL-E H 4PPROVEO By T44E
s U SPECTD13 ,PRWR TQ.A.PEBMIT.B,EWG GRANTED
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CITY OF SALEM (�
✓� ��' �',,� Date
s
Is Property Located in Location of the Historic District? Yes_No Building S (t"S k-v, ,7
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 Name
Address & Phone
Architect's Name
Address & Phone // )
Mechanics Name F4-d l
Address & Phone ZST ZNo1e,0? YZ Ice Doe, (0'i7)
What Is the purpose of building?
Material of building? VV wi> If a dwelling, for how many families? r
Will building conform to law? S Asbestos? f✓/�
Estimated cost �3 �� 3 0 City license t N A State se # &SoY$
jqg, Home Improvement
Lic. / 13 Stt X
Sig ature of ApplicatW
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
C��ol.��-z I�.k�� ��.,�ovt_ r -zbrE-(�rl� ,.� � �'a-ate►
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MAIL PERMIT TO: �c�S se—,Re- S wpm , `� " rn? ���, 0
APPLICATION FOR
Q PE/RLUT TO -
/�yylo
LOCATION,
PERMIT GRANTED
APP OVFD
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CTOR OF BUILDINGS—
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14
CITY OF SALEM, MASSACWUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. UlOVICZ, JR. TELEPHONE; 978-745-9593 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:
/ 7 (Location of Facility) (I Jo�
Cv
Si ature of Applic
�s - I �
Date
I
The Commonwealth of Massachusetts
Departn snt of Industrial Accidents
Office ojtnvestigatlons
600 Washington Strad
Boston,MA 02111
www.Measox/dla
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant Information j Please Print Let3bly
Name iOwbdivldaan._
Addre s: ZS�i s � K)A- ,
City/Statemp: A h evm— 1,11h"Me# C-<q_ Sl 0-`•(BU-u
Are you as employer?Cheek the•appropriate
Type of project(rogdred):
1.❑ I am a empioyer with and I 6: ❑New construction
employees(8tB and/or part-time).' have hued the to wonulws
2. I am a sole proprietor or Parma- listed on the attached sbeat t 7. PIRemodetmg
ship and have no employees These sub-contractors have S. ❑ Demolition
work*fur me in a w capacity, workep'comp.?insurance. 9, ❑ Building addition
(No workers'comp,insurance 511 We art 3 oflScda have11 Veit 10❑ repairs or additions
rwnced j. txoacrseil
3.❑ I am a homeownnt.doiog all work right ofeaemptrgfz per MGt" 21.Q Plumbing repairst>t addition
myself. [No wo kcW.comA. c. 152.jl(4X and we have'ao 12❑Rnofrepaua
insurance requirad l t. employees. [no workesi' 13.❑ Other
coup.;tea rdlorrcd j
hi
;Any aPv�and�b"I MUc a,u fin outt>le,ecbm below,to •
�s tbeq.,wo?ID{e'�ndn gooey ioSmmation:
t Homeowner wbo abu*�effdevit kftdiq&q are dome Awork end men ae ik"ooelnnetare mint submit a um effidevit indicating ench
tContncmn that elfwA ffiia bmi'MW athekad a W&ffl nd sheet abowi g the nwm 4flw=roonti�ioMn cod then woken'comp pokey mfonrmlioa.
lam ate antpioya that is ptwidbt;wor4trs'contpcnsation insurance jor my niipfoytes Bstowls tha po&y•rdJob alas
Infornrtatiaa. /1
Insurance Company Name: ( �Mi�letCcSu. �c—
Policy#or Self-mt.Lies #: d Expiration Daft: 7 !S cJ(o
Job Site Address:__ City/StaWZip,
Attach a copy of the workers'compensation policy deeiaradOn page(showing the pip )•
policy number and expiration date
Failure to secure coverage as mptaed under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
The up to$1,500.00 and/or one-year imprisoamen%at well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day agamsttheviolator• Be advised that a copy of this statement maybe forwarded loft Office of
bsvwdgation of the DIA for insurance coverage verification,
I As hereby cc rthepah►o and penahia OfRed &7 that the lOwn edon provided above is true and correct
fitialture: ��` - D . 3 . off
Phone
0,o?dal run only. Do net wrke in thls any to be completed by city oitown o,�lelaL
City or Town: PermWlJane#
Issuing Authority(drde one):
1.Board of Heakh 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person Phone#•
Information and Instructions
for**employees
Massachusetts General Laws chapter 152 requires all emploYas.to pro wo&9W comP��on
pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, .
expressor implied,oral or written"
An earPloya i$defined as"an individual,partners*association,corporation dr other legal entity,or anY two or more
of the forwing god,in a joint enterprIM a�includtng the� "E°of i deceased
tuplo cmpee Ho'ewer
n or other legal entity,employing�P of then'
receives or trustee of an individual,p�n��0C1 spartments 8no and who resides therein,or die oft
owner of a dwelling house havtng not more than three
dwelling hose of another who employs persons m do maintenance,cowncdon or repair wod *o m eemedVi an a."
or�the grounds or building aPP iheteb share not because of such empbymeat
be MGL chapter 152,125C(6)also "that"every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to constrnet buildings L the conamonwealtY for any
applicant who has not produced aeeeptabk evidence of compliance with the insu mace coverage required,
AdditionallY,MGL chaps 152,12SC(7)states"NeiW the commonweahh nor any of its political anbdivisiom share
of ublic wodt unto acceptable evidence of compliance with the insurance
� enter into any contract for die performanceP requirements of this chapter have been presented to the omst acting ty„
Applicant
iron affidavit complei*,by cbeclsing the boxes that apply to you situation and,if
Please frI out the workers'compensa ' with their catificatc(s)of
ucccssar5,,supply rob-convactm(s)name(s),addresses)and phone namber(s)along with DO employees other than the
insuuanee, Limited Liability Companies(uQ or Limited Liabil y Partnerships W)
members or partners, an,Pat required to tarn'workers'compensation insar m If an LLC`or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted tn the Department of Industrial
Accidents for comfumXdM of insurance coverage. Also be sure to sip and date the affidavit. The affidavit should
be rehired to the city or town that the application for the permit or license is being requested,not the Department of
Should you have any pestions regarding the law or ifyoa are required to obtain a workers'
lndnstrim Axide� leruse call the Department at the number ljsted below. Self-insored companies should inter their
compcnsationpolicy;P. . .
self-insurance license ntti on the h line
City or Town officials
please be sure that the affidavit is eompk c and Printed legibly. The Department has provided a spacyou r f Investigations has to contact egardinge lib
cant
of the affidavit for you to fill out in tenseba office�w� nsed as as reference mrmber. In addition,an applicant
Please be sort to fiIl in the permiNli Head=in any given
year,need only submit one affidavit indicating current
that most submit multiple perm vbccnse Opp
policy information(if necessary).and under"Job Site Address"the applicant should write"all locations in (city or
town}"A copy of Ste affidavit tW has been olHcasllY smmp�or marked by the tidy or town maybe provided to the
applicant as proof that a valid affidavit is on file fur filmic permits or licenses• A new atdavit must be Stied out each
year.Where a borne owns or citismis obtaining a license or permit not related:to any business or commercial venture .
(ie.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
ThaOffice of Investigations would Me to thank you in advance for your cooperation and should you bave any questions,
please do notbesitM to give ns a call:
The Department's address,telephone and fax mamba:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston,MA 02111
Tel.#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia