61R SUMMER ST - BUILDING INSPECTION • _ + t !,.��
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CITY OF SALE r4i INWSACHUSETTS
BLiMING DEP%RTMENT
' 120 WAMV4GCON STRI ET.P FLOOR
III IVI. (978)745-9595
FAX(978)740-9846
j M36l8ERI.EY DRISCOLL �.
I MAYOR THomAsST.PMRM
DIRECTOR OP PUU rr•PROPERLY/BtMDING COAL%USStONER
rs'Compensation Insurance Affidavit:Builder/Contractors/Eleetriclansmumbera
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Are` an emplayetT Cheat the appropriate boat Type of Project(RvIredly
1191, a empioycr with (- 4. ❑ 1 am a general contractor and 1 6, ❑New construction
oyeea(fall and/or part-time).* have hired the sub•eaa mctms 7. Remodeling
2.0 a sob proprietor or Parma- listed on the attached sheet.i ❑ g
p and have no employees These sub-contractaa have & ❑Demolition
ins form in any capacity. workers' ice••• 9, ❑Budding addition
wodms•comp,insurance S. ❑ We are a corporation aml its
I offee%have curcised their 10.0 Electrical repairs or additions
3,01 'homeowmer doing all work right of exemption per MGL !I.[]Plumbing repairs or adtGtians
[Na workers comp. c.IS2,11(4).and we have no 12❑Roof repairs
regttired j t employ[No workers' 13.0 Other F&RM
COMP-msumace required.]
rouq ' tAeeb mxal torn dwrdt aucne seaim adurshowiag tttdrmaMs•m�Ont�y tom•
•t wam su6adl ads aatdmrit indEaamg dmyae ddmg dl raked thin WMa lideommxtaa awm submit a am affidavit itdkau%ndc
{a wmsidW"c1wkdds:b=manaffac6Mm sddfoend den dewin tle gum of On A640straftrs sad*,*cr *eW ex p.policy hffix.daa
Ian as r abet b pmvidbrR workers'csayasastioa Guaraacefbr M P ea tpbrytes Below b rheFollry ondja8 ales
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Policy Nor Self-ins.LienM (ew c &40 9 C Expiration Dato:
Job Site Adehess 6 112 Suvvi me— City/SmuvZ. Salem. ,MA
Attach a copy of the workers'compensation Polley deelmilan page(showing the policy number and expiration dm*
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or owyear imprisonmeK as wall as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ortho DlA focvauMrtcrcoverage vcri icatien. 'k
! /do hereby cw*under tluepdiir sndpeenahba ojpffjwy that eke wfwwadan psavlded abow Is erne and coifed
Sienature: E -k-- Date: IQI tT(G :j
PhoneN: 7bl— 665- 16Ln
Q87clal ash only. Do not wnar In this area,to be corapletad by e1W of town ofiWal,
City or Town: Permit/Lbense N
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.Cilyffown Clerk 4.Weetr(cal Inspector S.Plumbing Inspector
6.Other
Contact Person:'
Phone N:
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Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970
(978)745-9595 EXT.311 FAX(978)740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
Construction Moving
Reconstruction X Alteration
Demolition Painting
Signage Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District: _ McIntire
Address of Property: 61 R Summer St.
Name of Record Owner: Susan E. Colford
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f� Description of Work Proposed:
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Replacement offour exterior window sills on the southeast side of the house to match the sills on the front of the
house. Repair and repaint house trim as needed to match existing.
Dated: June 11,2007 SALEM HISTORICAL COMMISSION
By: 1F 1I�
The homeowner has the option not to commence the work( g unless it relates to resolving an
outstanding violation). All work commenced must be completed within one year from this date unless otherwise
indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildines (or anv other necessary Dermits or aDDrovalsl nrior to commencine work.
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