18 WASHINGTON SQ WEST - BUILDING INSPECTION fL�N61d1�6fii�E fg*04ND APPROVED BY 744E
JNSPFCIGA,PWR TO A.FE MIT MING GRANTED
CITY OF SALEM
-/0�D�
No.(ss��G1l�L
Is Propedy Located in Location of
Rw Historic DW W Yes NO_ 11•i�a �� � �?-6h k�n /,�_
is Property LoraWd in
I*cortaarvatl4o Area? Yw 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:
Owrier's Name
Address & Phone - " c y 1d) 14• 'j o
Architect's Name N4
Address & Phone L-
nn
Mechanics Name r1�(� I e ,F
Address & Phone y �lore-,zfT Sale .
What is the purpoaa of txtlldW HD Te,
MdWW d b idlrp? n a dww",for how many IamiWes?
WN b kkV corMonn to law? 08?
EW=19d WN Gty Lim"• N A State Lena e
Harae LProesant X
4f 1 ' ` Signature f Applicant
SIGNED/UNDER THE PENALTY
OF PENURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No. y Dl
APPLICATION FOR
PERNQT TO
�enlP�e iP�6�x� �Um ram-;
LOCATION
PERMIT GRANTED
2.0
A ROVED
INSPECTO OF BUILDINGS
CITY OF SALEMv MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINOTON STREET. 3R0 FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOYICZ, JA. TELEPHONE: 978-743-9993 EAT. 380
MAVOS FAA: 979-740-9846 ,
Salem Buildlna Deus_ n
Debris DLq3wW 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
PmP Ylicensed solid was
te disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of pplicant
y -i9_,s
Date
M Commonwealth ofM4ssochuseft
Department oflndushial AwMents
Offla of.byrsdSoidow
600 Wa hkgtow Sheds
Bostoty MA 02111
trwwatensoulad
Workers'Compensation insurance Affidavit: BuHders/Contradors/Eledrictanr/Plamben
ADDlicmd W-Matioa Please Print Lesibly
Name hrn-lC,s� fir✓%per =, c
Address: y Glnrence st 3
City/StateR n , L i Phaae#: q z!' -7 Y< - 'NIJ
Are you an ero (egerT CIKek sir`apptgtrlate boa:' _ Type of project(rMgirea
I.M4 am a employer with 3 . 4. (21 am a general conttxeai and I 6. ❑Newemployes(Srn snNor part-time}a bambbid e a sov4doombm constnectim
2.❑ I am a sole proprietor or p~ Had on the attached sheet$ 7. 0
ship and have to empkryees There stib-eontraebn have 8. ❑ Demoliti n
workim fwseerin a w capacity.. i Oomp.humsoce. 9. [� 8 addition
[NO� , ,inmraa:e. S. We are i�cmpors —sad ib' 10.0 Mectrical repairs or additions
required 1..� otBCen 5aye eze their
3.❑ I am a homeowner doing all work right ofe:eM-t per Nick- 11.Q Plumbing repairs or additions
myself(No workeW,comp a 132,41(X sail aleLave'ito 12.0 ltoofrepaut
msaranoenquQodat: emp VW '
` .fir 13.[�Othes �,r: -
iesmance'
'Any appliuot not chub box al aLo 5fl ant 11N aaciaa Kalov dicer leer t�dt,Pwa�ep oonpee�soa PDft ia�oa
t Haasowara v4o mama tti aefia vit iodt aft Sq an dft an wart and I=bovidA .uwe.al uit a nw.®a.va indicants swop
&Cmignicitim oma Ankttiabu meaeadWereaddit WAMdawneytauttifft06voahtcowaadembwvdotn'emPPoftMfo+*tadom
I am air empkyertkaf ir pravidaa workers'eompcasaBoa brsarww fdr my Blow b tkapdky aslJob s&#
lejarwatka.
Insurance Company Name
Polity#or Sex-itp Lie, # k/c 693 a `t Z 5 Expiation Dace:
Job Site Addma- Lyty/S : S 91e� aver
Attach a copy of the workers' mpeosttion poft declaration page(showing the poncy number sod expirarioo date).
Failure to secare coverage as required under Section 25A of MGL c. 152 can lead to the ioyosition ofa®mal penaMcs of a
fine up to S1,500.00 md/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offim of
havaugado=of the DIA for iaiarance coverage verification.
1 a hereby wo w derA*pabu atdpexaMa ofpvj&7 Mar Mw IN&w adoa provfdrd above is true and ew7wft
i - D
d -
QfJdd mu only. Do no wr&Ix Ah a so to be coatpktal by c4 ormm o,(/kld
City,or Town: Per'mlitlucense 0
Issuing Authority(circle one):
1.Board of He&k L Building Department 3.Cky/rows Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N•
Information and Instructions
Masswbusens ur 152 requires all emP)M1MfA P*v*-wow'compensation for their mil'
General Laws c1uP is defined s"...every P into ie vice qfaootbe*.nnda any of l�
Yasnant to tbia ststute, an
ewpbyw enprese or implied,oral of writtCL
asaoei d^cmpastbs dr otha legal entity,a any two or mere
An eopmjyw is defimd ss an individual.pa<maship. ,a tba
of the imregoiag m6ag10d to a Jomt .ad 1°e�tt l� a 9f a decemad emploYQ
of at r e trmtee of an individual,parlsaft association or other kgal eodtY,employing empbyaea Howev!cg As
Noose having not m m than throe and who nsian ftsem,or the o�of'ibet
owner of a dwelling mamtemoce,construction or�wo*on such dwaing house
dwelling house of another wbo employs 1�a D wt becnw of swb emplcymem be deetd lo be an employs'
is on the pounds a building appwwud
MGL eb,w 152,12SC(6)ww states that"every state err local 9ceadsg agcmy shad withbold the baauec or
re sews,of a license or permit to operate a business
to construct budldisp V the eommoswealu for any
applicso wb bas ad predsad acceptshie midem of compUtsee with the imurasa coverage required.»
Additionaft,MM chapter 15Z 125C(7)states"Nenber the commonweahh no say of its political subdiwtona shall
enter into any connect for the perforMISOM of age wo*until acceptable evidence of compliance widk the insurance
requirements of this rhapta have boa pm aftd in the poMOCting "
Appgcauft situation sod.if
please gout the workers'compematwn afSdavn��'by t a box a that appbr b Ym
cea sa'y,euipPly wb-aontsa s)nme(sl Aben(ea)anal pbo t ems)along with their cestiScasds)of
trenuts aces Limited Liabt7dY Companies(llp or Limited Liability Partnerships(LM wift no employees other thsn the
members or partners,are not requirod 0 carry we*=,won�nes°00 if as I1.0 a LLP aces have
employees,a policy is required. Be advised that this dit vit may be submitted to the Department of htdastrfal
Accidents fa of insurance coverage. Also 60 fife to dp and date the affidavit. the af$davk s>t uld
cP=tucw Of
be returned to the city or town thate application for th the permit or license is being ngaested,not the D
budnstrial A=kcn s. Mould you have any questionst die law or if you an required to obtain s workers'
st&e umber)fated below. Self-iowred cgmpaoia should enter their
compema>ion livens on e lba
self-imumanee>imase
City or Tows OffieWs
Please be am that the affidavit is oomplete and Printed legibly. The Department ban provided a space at the bottom
of the affidavit far you to fill out in the event the Office of Investigations bas to contact you regarding the apPHcant
please be sun to 5.in the pamw1kemm tmrmber wbich will be used as a reference number. In addition,an applicant that court submit multiple pemu�ticeme applications in any given year,need only submit one affidavit iodicatmg current
pow'wormation(if necessary)and miler"Job site Address"the applicants ldwrito or�bca may�rovided to or
town}"A Dopy oftbe saWlsvrl that bra boa oflkWbr stsoVd AI>�cdby.. -
applicant as proof tbat s valid affidsvit is on fag fa future permits or licenses. A sear at1ldavh mnube OW rod each
s licensee a permit nit related.to any business or�eraial vesture
yea. dog license
a come owner a bum l is obtaining ts DW��to Mete this afldsviL
(ice a dog license a permit to bon leaves cote.)said person.
The Officeoe of Imresligatio m would hire to thank you is advance for your cooperation and sbould you bave any questions,
please do not bcdtate In give m a
The Department's addr ,telephony and fag mm6w.
The Commonwealth of Massachusetts
Dq tmed of Industrial Accidents
Office of Inustipdons
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