18 WINTER ST - BUILDING INSPECTION V,:0 S.Mw*,eE f4umkmo,Af"OVED BY T44E
II PECTLIB .PIWR TP.A PE13APT BEING GRANTED
CITY OF SALEM
0 ;. Date
No.
Location of
Is Property Located In Building /D
the Historic District? Yes_No
Is Property Located In
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Inst iding,S onstruct Deck, Shed, Pool,
Rep dReplace, 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:
Owner's Name
Address & Phone
Architect's Name
Address & Phone —�
Mechanics Name
-JoM Ser�.�.)
Address & Phone qo(f
What Is the purpose of building?
Material of building? << c\a p6 ew ZJ If a dwelling, tot how many tamilies?
winbuildng conform to law? `fc—� Asbestos?
�— c 5
Estimated cost �/°O p City License M N A State License ennse# Sh 8 6
B°ae Improvement
(� Lic. >? 2 ° Sign u e of Applicant
SIGN UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No.
APPLICATION FOR
PERMIT TO
LOCATION
J ? l�/tifer ��—
PERMIT GRANTED
APP V�D `
IN P ECTOR O BUILDINGS
r
CITY OF -Q1LEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3R0 FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. uSOvlt=. JR. TELEPHONE: 978.74S-9393 EXT. 380
MAYOR FAX: 978-740-9846
+Salem Building 1DPn9r4ennnf
Debris Dis NN 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:
1R 5 �`" " Vi I< (Location of Facility) C
Signs of Applicant
3 I� �0 L
Date
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CF.RTOICATE NOLOER '- __ ., �CANCILLAT10N
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SALEM, MA 01.70 Ni4 aaUCAT10a OR YAWW" 0. AM PNO''A6N YA■INC AS■ rL m■r.a or
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600 WaWxgtw�Strad
Boston,MA 02111
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Workerae Compemdon Insurance A®davit: Boflders/Contndors/ElectddansINumberg
AQDNcant Information C Please print Leslbly
Name Co
Addresss,.•��„.,
Q1Y&tatelLijt: Phone th -�8 I — SSx-n 7 3-
T�
Are yo Isn"M r! '>t a t¢aprinta boar' m of Project(regalred).
I.el am a employer wick 4 I an a geaaal aonusew and I ❑p
employees(ibn and/or part-time e, hnvabkad the subaoasaclma
2.❑ I am a sole proprietor of partner Had on the attadied stint i 7.
Qlemodeligg
ship and have no employees These bm 8. ❑ Demolition
wwltiWibcmam any"pacity. i°COMIL insmisoL 9. ❑Buildin addition
(No worked'comp.fmaance S. ❑ We ace a ampQration and ia' .
1R❑mectriealrtpaas or additions
regmirod}, offiod>t>isye eseieod their
3.❑ I am a homeowner.doingap work T*Of per MGL' 11.Q Phmrbiog ttpava or additions
myself Rk wodwW wmp Q 152,jl and tVehava'no 12 Q ltoofrt abr
hommoenquuedr,}t. eIDPby 'woitai°.� 13.❑ Otba
r.
;Any applieadthd d-1-box ai coot don 68 oAdp notion below deicing meirw'I.IRW yulieY mSoimafoa
t Han vowenes motto eubmtt sfBdavR iodiwWoa melt m doing eA work end anne b000t tbtmt a new dBdevit iodic mean
tConnseWn did ebwk:bb boa'MW d"W ell edditlond°beet Aowteg the rots bfnbesbomRocbwmdeenkwe&=,coal.policy mfos'mdiM
,ran qr employartliat b p vpiaua wurkm"eompeardtm h sww w fer myArpf6yraea allot.b&ep*&7 a 4joa a 4a
hsfiffne tan.
Instu=e Compsay Name �i+w. •>k
Policy 0 or Seltfims.Lk Eapft d=Date
Job Site Address_i5l 1�• v 5 Sa t.-� (ytymateanp: Sce'Au , Yti_ 0 kC%b '-
Attack a copy of the workers'eompensudes poney dedaratlos page(abowing the poney number and expiration date).
Fal7me to same eovenge as required under Section 25A of MGL t:. 152 can lead to the imposition of erimind penalties of s
fine up to S 1,500.00 and/or one-year m>prisomoem,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$250.00 a day against the violasor. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for inanramce coverage verification.
I di hereby cc777Wand pensblet ofpgjW that the Lrformadoa provided above is true and cw7w"
i D t5 0�
SS3�-
O,aleJd ass mOL Do not wrLtt hr tits area,to be compAWd by eifyorawn odldeL
City or Towns rermit/llernse err
Issuing Authority(cirde one):
1.Board of Hakk 2.Building Department 3.City/Town Clerk 4.Eleetried Inspator S.Plumbing Inspector
6.Other
Contact Person: Phone 0•
Information and ,Instructions -
Massac>ausats General Laws chapter 152 Mein an emp1oym *>QV*-�qW 4a i notha � of their lei
Pmauant to this smuts, an mw1ey"is defined as ...every person .
xim
apress or Molied,oral or writta.'
Or O&a i�entity,of any two or mor0
A the fors v ij defined asp ? Mh do gfa decwsad emP>��Q
Enpvd.• association or other final entity,ampbying empbyecL
receiver or trusses of an b&Vidoai,p and who resides&crcia,or the ooapant ofihd'
owner of a dwelling bonse haviag not more the three ccnstrttction or 1ePau wort#on sack dwelling house
dwelling house of stnther who employs persons to do maintenance+ be deemed p an�P '
or ca the gromde err building
appnroeoant
thaeb shall not becaose of such empbymeat
MGL chapter 152,125C(6)also states that"every state or local reeadag agete9 sitar wtthYold the htsaatsee or
rewwal of a Seem or permit to operate a baslws or to eonsbud barNep V the eo°sm°aw�for say
recent who has not predated seesptabte evidetee of compliance with the Maw""coverage required.'
Additionally,MM chapter 15Z 125C(7)states`NcidIC the cemmonweabb aor arty of ib polidal subdivisions shalt
of be work moil acceptable evidcM of compliance w�the insurance
eater into any of
c4 apt the performance to the contracting aatbos>W-w
requirements of this chapter have hem 1>�
ApPikanft nitration and,
lion affidavit tomPleoe>y,by cheetmti the boos that apply p Y�
if
Please�out the"Odgers'compataa s with their catificate(s)of
sub-coanacpr(a)name(SI address(a)=0 phone umber()a�6 other titan tba
mmraoce. Lmtfed� Liabilay Cmul aties(tub or Limited Liability Pattsash>ps(1J-P)with m employm
members or perm%are.not�°d p�Y wodm' �mearanca If an LLC or LLP doer have
employees6 a policy is required. Be advised that this affidavit may be submitted to the Department of lndnatrial
Accidents ccnfirmatien of immance coverage. Also btt safe to sign and date the aAldaviL The affidavit should
be returned to the city ti Lowe that d1e spplicadua far the permit or license is being requested,tot the Department of
Indnstial'Accideda. Sbgald you have any questions regarding the law or if you an requited to obtain a '
arm1 bated below. Self-inured companies
should enter III*
compensation Oft pleassi can the Departaxatat the n fine.
self-inamattce license mmb�0°�
city or Town fNddals
please be sine that the afdavit is complete and printed le&ly. The Department has provided a space at the bottom
act egardimg
of the affidavit for you to fin out in the eventOffice
bcr bic o—b will be used as a reference number: In addition,211 applicant
please be sure to vestigations has to cOnt you r the applicant'
fill is the pernuNticense lications m any given year,need only submit one affidavit indicating current
that matt submit multiple permiWeense aPP
policy information(if necessary)and°�"Job Site Add[W the aPP>�should write"all locations m (eQy Or
town *A copy of the aflfdsvit thus has beau o�ci ft s�Od oL>�ed by the�3'or Iowa maybe provided to the
f that a valid affidavit n on file for fitmre permits or licensees A nets affidavit must be fined oat etch
ywr�Whencant as abome owner or citiaea is obtaining a license or permit not related,to any business or commercial venture
(ice a dog license;or puma to bum leaves etc.)said person is NOT rNuhvd to comphge this affidsvh
Thor Office of Investigations would like to thank you in advance for your coo paadon ad should you have any questions,
please do not hesitate to give ins a car:
The Department's address.telephone and fa mmba:
The Commonwealth of Massachusetts
Dgwtntent of Industrial Accidents
Offitx of Invesdpdons
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