167 FEDERAL STREET - BUILDING INSPECTION r _
® r • 16 7,FEDERAT STREET
Plans must be filed and approved by the Inspector before a permit will be granted.
,No. 7 % 93 City of Salem ward
Is Property Located in the, / t�
Historical District? Yes No_
eHome Phone#
Is Property Located in a
Conservation Area? Yes_ Noz �'+,pBus.Phone#
APPLICATION
FOR
PERMIT TO Fro,,4 Do or
Salem,Mass.,
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for apermit to build according to the fo lowing specifications:
Owner's name and address Gov o t�/1Sc�i/
Architect's name
Mechanic's name and address
Location of building, No. 67 P
What is the purpose of building?
Material of building? Gy00
If a dwelling,for how many families? /
Will the building,conform to the requirements of the law?
Estimated cos —��rfl�' Contractors Lic. No. ��i 0(35- 7 oM8MIZ
7ign ture-ofapplicat 7/8
SignedUnderthe Penalty of Perjury
5 �J(/ �G(� d
No 9/ ,,9 Ward
APPLICATION FOR
PERMIT TO CONSTRUCT
SWIMMING POOL
Location / 6 7
PERMIT GRANTED
is
Approved
1
/occ J itding In pector
a�
COMMONWEALTH OF MASSACHUSETTS
�' DEFARrmENT OF INDUSTRIAL ACCIDENTS
9�,L,�' 600 WASHINGTON STREET
fames.: Camooe' BOSTON, MASSACHUSETTS 02111
om^ ss one I
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
(I icenseci perminee)
with a principal place of business/residence at:
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that:
k,?11 am an employer providing the following workers' compensation coverage for my employees working on this
job.
Insurance Company Policy Number
[ ] I am a sole proprietor and have no one working for me.
[ ] I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
[] 1 am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL C 152,sect. 1(5)),application by a homeowner for a license
or permit may evidence the legal status of an employer under the Workers' Compensation ACL
1 understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to$1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
f ne of 5100.00 a dry q
Signed chi day of o/ / )r / 19 /`L
Licensee/Permirtee Licensor/Permirtor