9 SURREY RD - BUILDING INSPECTION a
�1,�MSiNiiS��E{.{Lf8--A+M.APPROVED BY T44E
IAISPJ:CTL ,PF3JOR TD.A PEMT B,EWG GRANTED
CITY OF SALEM
Date D-IS �
Is Property Located in Location of
the Historic District? Yes,_No 13ui1din6
Is Property located in
Me Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, nstall Sidin 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:
I
Owner's Name n v't�c 10�`I�GNr TTln/D
Address & Phone
Architect's Name
Address & Phone
Mechanics Name n�/�c/ GiryPaner/a�rGTo�y
Address & Phone Lfr ow, r9x1 S3!'16%f
What Is the purpose of building? ���� )P'Vr g&
Material of building? 11 a dwelling,for how many families?
will building conform to law? Asbestos?
Estimated cost UDD City License# N A state care#
Hose Improveme t Y
ah of pf nt
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
J
MAIL PERMIT TO:
No.
APPLICATION FOR
PERMIT TO
//VsT.4GC L111411L cLLLA/6
LOCATION
PERMIT GRANTED
APRFJOVPD
7P,$QTOROFBU—lL INGS
1
1
The Commonwealth ofM"whrrsdts
Department of Industries/Accidents
Orcle 0j1mtesd9tons
600 Waskingwn Sbat
Boston,MA 02111
wwtt Mensmad
Workers'Compensation Insurance A®dsvit: Builders/Contradors/ElectrldanyP)nmbers
Applicant Information Please Print Ladbly
Name po lga C IVY CoPT118Acrc>es
Address:_, ,ram(, &At_ WALNUT s'_ t)Alir"t
City/stawzia ,A those 0 9?e_ sra ►- l6Qg.
An ou n er!Chtek tlrippeoprlate boss'
It
Type of Project(mdred):
1.An
am a employs with 4. (2 I am a general contras or and I
employees(W and/or past-time}' have hiked the sd�a kuadm 6: ❑New conetractiomm
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ®Remodeling
ship and have no employees These nab ao rs have 8. ❑ Demolition
WOMB&far me in any capacity.. Win comp.imulanoa 9. [:]Building ilding addition
(No worhess'comp,insurance s. ❑ We are a omPoraum ao4 ifs' .
raq�Y offices ffiea 10.0 Electrical repairs or additions
3.❑ I am a bomeownw.doing all wak right ofeze'mptiga per MGL' 11.0 Plumbing repass or addition
myself[No wmkcW.comp; a 15Z f lot s, ale have no 12 p Roofrepaua
ma°rao°°regni<ed j t avbyccL
v a i"aj 13f] other
;Any appliemt tde oheeb boob rt mis also q welq{wctiaa below drowWg e* - .
t Homeowma wlp zu tad. davit mdieirfoea p�eA welt and lbee )pier
h�oohfd�mmiic0�emuRabm&ee�washvitiodicetfigach
=Conhacbnnrtd�eettbbbo='imtalfrtehadaeddnbodadetadwioattena�tiflttaoeeb�tlenandn�ew�tan'em4tutii]'mt'ornyRioo. .
fare gr employes rA�ef lr provlJ�;awrkarNeoarpauedos brawnaee fa ar�sii pfoytes Bdow le tilt pat?wid job sift
InsaranxCompanyNama /—l(jt�2l`� {I�IUit/19L /IJS �6
Policy#or Soh=iot.Lic.# Expiration Date
Job Site Aaaraa ' /J clty/smwzip: �S/�G�ti lr-C�� o%�i76
Attach a copy of the workers'compensation poney declaration Page(sftowing the policy number and esptratto,date}
Failure to secure coverage as requited reach Section 25A of MGL a 152 can lead to the imposition ofaimind penalties of a
fine up to$1,500.00 and/or one-year WVTb0UMCfft at well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day againstt o violmr. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insormce coverage vai&XdDL
I As hembyetro anderae endPAIdda olPffjW7 Aar the Inja+nadex provided abow is aw end entrees
Sionaaw, Do,
O,olcle/am Doll► Do ed twba bs fhb any to be coaptdid by cAV mown gdWd
City or Town: Pumdmcnu#
Issuing Authority(circle one):
1.Board of Health L Building Department 3.Cfty/I'owu Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone*
Information and Instructions
. compensation for rhea employes.
Massachusetts General Laws chapter 132 requires an emplaXai:10�rvice qf another under any contract of hire,
Pursuant to dots statute, as empkyj is defined as"...everypason
Or implied,Oral Or Written.
associadon,empmalan&Otha hgal eOtrtyr or any two or m0r0 "
An empleYdr a defined as�an i p nd kchaft the legal r of dotxesad eMP10 O
f IM
of the for i.eg O peo6 l anoc&*D or otha legal entity.emptying ampbyaa Q
receiver or Ims of an mdivid A panneraw and who resides therM or the ouopaat of i i t'`
owner of a dwelling house hang not more than three ennstrtubon ur� on rater dwelling
buffie
dwelling lame of another who empbys pasom a do maintenance, f such empbymentbe deemed to be an aVlOYa."
or on the gtottads orbntldmg appmteoant&crew shall not because
MGL chapter 152,12SC(6)also states that"e'er Oft or local Utentflag&9"q des wttlthald the karma"or
or to constrad t110 C811111mmaw"M for my
rtmewal of s ttcenae or rottaoro evldta dt0O pU m`buildings 1Wvu06 cGvunW regairy �
applicant who has not p es of its potideal subdiv�o�
Additionally,MGL chapter 15Z PSC(7)sues"Neither the commonweshh any
cuter taro say c°nuact for the perbu anc�e ofl��wo*until acceptable evidence of compagam with the immranca
rewint an of this ch,,Unbcapramtedogwomgwtmgn» j."
Appkmu
affidavit eomple*,by checft the boos that apply b you dma*m and,rf
p�5q,opt the workers'compensations with then catificate(s)of
necesaaty!,supply tea)name(a�addnai(es)aq1 phone mtmber()along with no byes other than the
inanrialM Limited tkbitily Compaies��or Limited Lisbihty ParmeBh�pa(if an
members or panacea,are,not requited to cazryw°rken'opmpcasatioa ias�nce If as LLC or I.Ip done have .
employees,a Poft is reQuired. Be xhisad that thin afBidWvlt.may be mbmrtted a the Department of brdnstrW
A�eny far of iusarance coverage Afro bq,am to alp and date the aMdaviL The affidavit should
be returned epartancetOf
a the city or town 69 die application for the pettait ur Heenan is being rcgnestsd.sat the D
hrduatrial pccidems, Should you bave any pedtiom regaoidmg>� bbebw Self-mooredeompamea she»M enterenter you are required I*obtain a ' their
poft pleastt the Department at thecompziasadm m,mber paled
self-bsw=w license ttogig one
te tines
Clty or Town Olndad
please be we that the affidavit is complete and Printed legtbty. The Department has provided a space he applicant,
the bottom
of the affidavit for you to fMp out is the ev °f Iffveatiptions has to contact you regarding
w as a reference amber. addition,an applicant
please be sure to fill in the patmtnicense bkhtb�ticadmin in any given year,need only submit one affidavit indicating current
that must submit makVle PamWhmw aPP
P�ltey a(if necessary)need under"Job Site Address"the applicant should write"all My be a in (dry or
ofthe'sifidavit that has b�officialbtslaQaed--.nER �° 'or tower may be provided 1b ih0
town}"A copy '�afdai*mil the filled out each
appicant as proof that a valid affidavit is on filn liar f4mre permit or>tc m wmnutid venture
ear.where a home owns or cdmm is ob�iog a lice me Of pamu But Fdattj,to any business
y
(le.a dog ticeme or permit to bun laves cte.)said person is NOT required m complete this aftM"
The Ofaoe of Investigation would hlte to thank you in advance for your cooperation and should you have any questions,
please do not hesitate In give us a cafi.
The Dcpartnaenes address,telepbone and fait number.
The Commonwealth of Massachusetts
Department of Industrial Awdents
office of Invesdgsdons
600 Washington Street
Boston,MA 021 It
Tel. #617-7274900 ext 406 of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26A5 www.mass.gov/dia
CITY OR $ALEMo MASSACHUSETTS
• • PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET. 3R0 FLOOR _
SALEM. MASSACNUSETTS 01970
STANLEY J. IISOVICE. JR. TELEPHONE: 978-745-989S EXT. 380
MAYOR FAX: 978-740.9848
Salem BWldins no.,�......-
Debris E611081 Arm
In accordance with the provisions of MGL c40 S 549 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:
1 J AST (Location of Facility) L�Dooy� colt
4SigPnof Appli an
Date