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60 WASHINGTON ST - BUILDING INSPECTION (3) y , .IaL.AM jaffiT-eE fiL{�*W A?PROVED BY T44E .WSP,IECTAR PFWR TD A..P.ERMIT f3,EWG GRANTED \ \1 CITY OF SALEM NoR�\ �• � Dale s r.. -if Is Property Located in Location of the Historic District? Yes No_ Building 610 S. i , 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: C- r --� Z 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 Co, hn ( C o e� C5 L�,c • ��+.� S o � Address & Phone S 3 s n�_y ar ;asp (20�) (a W 4- ;L 4 ti 9 Architect's Name W M( 5 A r ,`, A-acAL Address & Phone 78/ 3et-,4 eD-e MAy,Ldl 0 H OYd 3 �yw Mechanics Name Address & Phone � �"� 14 /! Whet Is the purpose of building? Material of building? ..ten 91�j If a dwelling, for how many families? Will building conform to law? y '5 Asbestos? /'j G4 Estimated cost a,N City License • N A state License M C S O(a�5 /c� Berne Improvement Lic. / Sign ure of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: j,� }z,�a�t�'1�tif l�✓t rig- ��tiQ . > liar 'cam l/LJ+- 0!�(e y' NO. APPLICATION FOR PERMIT/TO LOCATION r, PERMIT GRANTED APPROVED L ECTOR OF B ILDINGS - t 1 4- o . C� David Latta co-owner coastal Treats db.&Ben 69 Jerry'se 91 Chadwick Street North Andover•MA•01845 Phone:978-390.3277 dlatta@coastaltreats.com . An tr�pmda�ryyovnm®anmr a w��®says ®Ben®,�eays��rmdv�uraroa The Commonwealth of Massachusetts Department of Industrial Accidents ' - Oltl�eo/Imres�atl®ns 600 Washington Street, 7`a Floor Boston,Mass. 02111 r Workers'Co m a isation Insurance Affidavit: Buildin lumbin lectrical Contractors 5 V 5 address: �Z)C�Ca,-..y 9,keL,— city tN i ?�i state iM A- zip q Z.O l� phone#/ 7f'6 4 ? -Pe/`--D work site location(full address): ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole 2roprietor and have no one working in any capacity. ❑Building Addition - - am an emplidikers-compensation-for my emptoyeesworkin�on thisjob oyer-provng-wor COmnasY nAml: l "'T �.� yt { .�..�.p¢�° $,�, s 4✓ty rz 4 �p- address^ city: s t ,q.« :.a<a ✓ �t;..^,+ o110n1:K'' 4S _hd"i �4i�n% V,^•F §+ d )�?'4 wf.�1-n mllev W ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comoanv name: . . address: city: - nhone# t'u "w..if' , '" , company name: address:' 5+.:'� <.C' "'.' _....++.gin?" �1 «�{"x-+x.,-'`•u..,.. ..s+ .. Y A v.. "'^'` ._ in r >r Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up a$1,500.00 and/or one yeah'imprisonment as well as civil penalties in the form ors STOP WORK ORDER and a fine of$100.00 a day against me. f undersand that s copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. l do hereby certify under the at is and p nal' of perjury that the information provided above is true and correcct. signature Date 6/(G ;— � n Print name '�-O��'f''� �'�d6-(-E-L Phone# 7 J aF'GC,..7 -9IV u17 official use only do not write in this area to be completed by city or town official - city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑ffeallh Department coned person: phone#; ❑Other I rensN Sept.SIMn) f Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state o rlocal hcensmg agency shaltwlth hold the-issuance-or-- - — renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be for confirmation of insurance coverage. Also be sure to sign and submitted to the Department of Industrial Accidents g date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if obtain a workers' compensation policy, lease call the Department at the number listed below. you are required too p P Y P Y q City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which-will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. yam 1 _ . MM The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of lnlfesdgetion 600 Washington Street,7'"Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR l SALEM, MA 01970 �-' TEL. (978)745-9595 EXT. 380 FAx (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition — - of-Buil Pem-it# - - , all-debris-resulting-from-the-construction-activi- dmg - ty---- ------- governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S 150A. n The debris will be disposed of at: V� Location of Facility 313 4 Sig—nature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) S r Name of Permit Applicant Firm Name,if any 7 ..4-A_`Ph—L--L `C A-t-La zL4 k✓k- cold` Address, City & State The above statute requires that debris from the demolition,renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. J � BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number,,,CS 068596 Birtisaete tW-n957 ';Ezples: 006 Tr.no: 28316 Restrktetl ROBERT J KAHL` -- GAY ST N �/ CHELMSFORD,AMA-i88.013 Commissioner CITY OF SALEM,MASSACHUSETfS LICENSING BOARD 120 Washington Street Salem MA 01970 978-745-9595 ext.421 ROUTING SLIP The Salem Licensing Board requires each applicant to have the appropriate Departments sign this Routing Slip and return it to the Licensing Board Office prior to the'ssuance of a license. BUSINESS NAME )—q- C°rp°rate name: `' �� LOCATION: C� i�1�.s� , !2� S�t-'" �i C1�G�� Tele.# TYPE OF LICENSE: APPLICANTS NAME: �- ✓1 `'/ Residence Street S-� ,S'�'i v;• %n� � Home tale.#��7 j`��lJs State: 1J Zip: City: (/U z TO ALL CITY DEPARTMENTS: your signature on this form is notifying the Licensing Board that all requirements of your department have been met,at which time the Licensing Board will issue a license. Salem Historic Commission 120 Washington Street Sign Review/Planning Dept. 120 Washington Street Salem Health Department 120.Washington Street Fire Prevention 29 ort Ave. ding hasps or 120 Washington street Department Pu blic ublic Services - - - --- - --------- ---- - -- 120 Washington Street WWma slip