96 SWAMPSCOTT RD - BUILDING INSPECTION (7) Cr -pf 4 y q
oo � �-
-pLtmSilAk Sf-9EfiL{�ii�1D.APPROVED BY T IE
W3pZCT0_s ,PgWR TP A PERMMIT 13VNO GRANTED
CITY OF SALEM v` `" %� Date yf
No. it
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:.(S-%F�b Zz fjf,�-rj-Tj ort S
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
9lnutT
r3 cart Fbltt"T ft*'v e r,3a - 7030
Address & Phone
Architect's Name ri ri t—i ��5
-715 5�
Address & Phone
Mechanics Name l
Address & Phone t
What is the purpose of building? ut'S o cCk) EL
Material of building? - s� 'f a dwelling,for how many families?ILA
Will building conform to law? Asbestos? N
Estimated cost
41,10.0 city ucense• N to State 4pp'
Home Improverent YLie' # IA, ignature ot
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
F-0-c- 1�totlz� �—
lp.F P
MAIL PERMIT TO:
No. Z
APPLICATION FOR
PERMIT TO
'
���Pl1`b/ TGnyiG�rtTT �\,
w/0
LOCATION
PERMIT GRANTED
A ROV�D
,arch
I SPECTO4ZOAILDINGS
i
The Commonwea/t¢ofMassachusetb
Department ojlndustrid Accidents
0,o4ce ojlarvestigations
600 Washington Suitt
Boston,MA 02111
wwwatascgowl4i
Workers'Compensation Insurance A®davtt: BuDdeis/Contractors/Electrkfant/Plumbers
AyIlUcant Information Please Print Legibly
Name
Address:
city/statemp. Maas M,
An you u esrT Cbtek the aPProPr '
a9: Type of project(required):
1.❑ I am a employs witA 4 01 an a Smesal contractor and I
�pbY�(M and/or part-time * bave>�ed de soV on adora 6. ❑New coasnoction
2.❑ I an a sob:propticidl or partner listed os the attached abext:t 7. 0 Remodeling
ship and have no employees These sub-aontracton have S. ❑ Demolition
[No workers'
Spry s ❑ W a tpe>raploa 9.. Q Bu�OB addition
r«p,�ea r
officdi►hays eaenoul tau l0❑Electrical repairs or additions
3.❑ I am a homeowner doing cep work 'per 1AM" I1.Q Ph imblog repsha or additions
myself (No weukOW Oomp- c. 152,j1(A ao .gp hsve'ao 12 0 Roofrepurs
insgranrt raiuhvda t• etuployea CNO.woikai' ME] Other
e»mp.in mange ragnilrcd J
;Any applicant t M chats bent ill tons also 69 avtdtc usticn below dwwios melf.wl�n�coureandos Policy a-
t Hoaeowms wlp�tmitthi.a6idavg iedfetlloi [w doiaa aD wwt and tun t aahid�oo p6nIDuR aahmg a new a®davg ion such
MM
fContraetan tSA ebaettbiabcnt'imt ahehed ere adNd000l�hwt�howni{�a oa>♦MtXrat*ooedklon�OtheiwrbmY'cao4 ply mfo+�+�ioe.
lags q e+itpinyar rhar b p'o►Wna twniara'eontpauatlom laaarurrer ja aeTeiipfayyses allow b tM pellet oui fob silo
tnjo arA"
Insurance companyName
Policy#or Self IDa.Lit # Expiration Date:
Job Site Address City/Stsftq*:
Adult a copy of the workers*comptan dos pelt declaration page(&bowing the policy number gad apiratton date).
Failure to secure coverage as required under Session 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine cep to$1,S00.00 and/or one-year imprisonment,as wen as civil penalties in do form of a STOP WORK ORDER and aline
of up to$250.00 a day against dwviougor. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of tie DIA for iu nume coverage veriamdon.
I At herebpcoo andnthapan and psndNo ofpsrlrrry the tha 100rosadom provlded above b Nw and correct
Vann= Dam
Phone t
D,�'leW µfa oal� Do acr wrbe Gs tlib ana,m br eoa►Plesrd bl cL4!a►bww odleld
City or Town PUUWL oenae Al
falling Authority(cirde one):
1.Board of Resitk 2.Building Department 3.City/Town Clerk 4.Electrlw inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N:
'r
Information and Instructions
compensation for their employea ,
Massachusetts GeWeral Lava chapter 152 requires all employeq loin&c rvice Rf another under any contract of hue,
ib
Pursuant to is statut% an swploya is defined at"...every personexpress µ
or implied,oral of written."
ek do
pa ,yr is defined as"era individual.Fatmersbip,aasociati0k ampaatioo iir other legal entity,ur say two or mine .
of the foregoing m6s is legdreprd�tivea 4f a deceased empbya,or the
associations other legal entity.employing employees ''
receiver at trustee of an bdividuat p and who resides therm in,or the oaxatpsaR of thd'
owner of a dwelling bouse baving not mire thin three bona
dwelling bowo of ai oaa wbo employs persons to do mamtenwok construction ur repair w.0*an sock dwelling
th
the gtotmdg orbni]ding eses shall rat because of such employment be deemed so be an emPloy
or a»
MGL chapter152,125C(6)go state that"every state or load deeaslag ageaey stag withheld tie bows"err
raewd of a seem or permit to operate a bndam or to emiltmet b6000 la the eommoawao for ssq
applicant whs bas ad prodnced aaepnble"mean oteomPtiasee with the lagarttaee eaves s rdivisi d»
Additionally,MGa.chapter 15%125C(7)state+"Neither the commonwealth nor any of ib political sabdivlalums shall
contract the perfmmana ofpubtio we*Wald acceptable evidence of Compliance with the insurance
enter into say the ooeCacfoK aaaitp."
requremens of thin clops bave been presented Is
Applleasb ..
out the workers'compensation affidavit c=Vkt*•by the bores that apply b your simatioa sad.
if
Please fill,necessary'.7 s)name(sh address(es)and phone:mpber(s)along with their certificate(s)of
SUPP rids(LI.C)or Limited Liability Pasas�(�)with no employees ode duet the
members or partners,are not required to carry worken��ompenaation fimmoe. If an LLC or LLF don have
��,�a policy is requred. Be advised that dds affidavit may be eubmmued to the DeParmxffi of industrial
no the Department Accident for of insurance coverage Alan bi.gore to et8!and date the xMdavlL 'the affidavit sbould
be reuuned to the city of town that the application for the permit or license is being regnDepartment
hidnsniai'Accidcma. Shonlit your a eDy 4ens� the btw or if you an required m obtain a wa&MP
Compenaatioa poft plMe call the Depertment d the Wombed below- Self-insured:oompa>un aboard eater their
self inmiuranca lirkase mo>m .on the lose.
City or Town 01acials
Please be sore that the affidavit is complete and printed legibly. The Deparuncm bag provided a space at the bottom
of the affidavit fees You to fill out in rim event the Office of Investigations bns ro contact you wgaphug.tbe appfi�
PW=be sire 0 fill in the permidticcuse numbtr winch will be used as a reference member. In addition,an applicant
nag submit mnitipb pefmiyhcenae applieatiom in any given year,need only submit one affidavit indicating current
in5ot nation if�ssary)��"Job Site AddreW the applicant shouid write-all bcstiom ID (City or
' of AlgaBfdavit narked the City or town may be provided to th0
tliathasbnao» ritL._ . ,bX _._ s_
town} A ooPY ee gccom sew afyidavit ib iitbe MW out each
year.Where
erg a ome o a valid cithmrt bon fib for licefimnse
a Pertain not rdaW to any busiaesr of oommereial veotow
year.Where a bona Dana or Cititxa'it obtaining s licemtae of perms mcomplete this affidaeit.
(ice a dog license or permit to bum leave$etc.)said person is NOT required
The Office of Investigations would bite to thank you in advance for your cooperation and sbould you bave any questions,
please do not hesitate to give us a c-A
The Departrawt s address.wlepbone and face numbs
The Commonwealth of Massacbtlsetts
Department of Industrial Accidents
Office of Investigsidons
600 Washington Street
Boston,MA 02111
TeL#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwmass.gov/dia
CITY OF SALEMq MASSACMUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACMUSETTS 01970
STANLEY J. UEOVICZ, JR. TELEPHONE: 978-745-9599 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buil& DensLrcn,a...
1_kbrla PhImosid 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:
v (Location of pacility) �2 �*� f �h� t�" 4
Signature ofVp�lica—nt —
D-`