16 BARSTOW ST - BPA-06-746 SLIDING GLASS DOOR -PL*NS*MTeEf4L*94N0 APPROVED BY T+IE
WpX=D8 PIP" TD.A.PERIWT REWG GRANTED
CITY OF SALEM /
—�� DateG Z�Ei
No. �-Dh
s: it
Is Property Located in Location of
the HistoricDlsidct? yak_No_ BoilAinB
Is Property Located in
no Conservation Area? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) "qpjir/Re
of, Install Siding, Construct Deck, Shed, Pool,
la , 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
Address & Phone q' h� /z-*� /4""26 (�� )2Cs--72-ST
Whet is the purpose of building?
Meow of ? If a dwelling,for how many families?
wW butidfrq conform to law? Ast>astos?
Estimated coati•w City License N N A state License
m— improvesent
Lie. i 12-9 o Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE / //�
20�(c� S(' ��Y CC,F SS 1! 6,
MAIL PERMIT T0: �/leoLL/Ale(Z-
No.
APPLICATION FOR
PERMT TO
LOCATION,
PERMIT GRANTED
2.0
APP D
7V //l
INSPECTOR OF BUILDI S
CITY OR SALBM9 MASSACHUsItyTS
PUBLIC PROPERTY DEPARTMENT
is 120 WASNINOTOM STR[[T. 3110 FLOOR
SAL[M. MASSACMUSWS, 01970
PAArOA
STANL[Y LlSOYIC[. J11. T[LaPHON[: 97S.74S-9S99 EXT. 380
M "
FAX: 975.740.9a44
lDl B Id Ds DED �nwn�
DTI 1)%Mnl Rn
In accordance with the provisions of MGL c40 S 549 a condition of your
Building permit is that the debris resulting from this work shall be dis sed
° a Properly licensed solid waste disposal facility as defined by MG
Chapter M. S 150 A.
The debris will be disposed of in:
(Location of Facility) f �/
Signature of Applicant
34-6/ko 6
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations .
600 Washington Street
Boston,MA 02111
wwmmass,gov/dla
Workers' Compensation Insurance Affidavit: Buiiders/Contractots/Ele 1 use Print Legibly
Applicant Information n-
Name �cn/I�ividual):__���1��
Address: cef
,L atfl3Z_ Phone
City/State/Zip: `�� ��'L�� ��
box: r7E
f proje7(requir4eNd):
Are you an employer?Check the appropriate I am a general co»iractur and I
1 I am a employer with 2 a e � snb coactnrs New cw
employees(M and/or part-time). Remodetor or partner- listed on the attached duct t2.❑ 1 am a sole pmpri These sub-contractors have Demoliship and have no employees workers' comp. insurance. Buildin
working for me in any capacity. 5. ❑ We are a corporation and its
(No workers' comp.insurance officers have exercised their 10.❑ Electrical repairs or additions
required.] right of exemption per MGL
- 11•❑ Plumbing repairs or additioffi
3.❑ I am a homeowner doing all work
myself (No workers' coop• c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.anc(No workers' 13.0 tither
comp.insurance required.]
*Any applicmt that cbsc]b box. l must also fill out the section below showing their workm'conven"m Policy infometion:
t Honmwnem who submit this affidavit im&cdmg they are dower all work and then but outside contactors must subnd a new affidavit m&cating such.
tContrectms that check this box moat attached an additional sbeat showing the name of the subcontmctore and their wmkem'cO'M policy mformn ioa
I am an employer that is providing workers'compensadon Insurance for my employees. Below Is thePolleyand fob sNs
tnformaHon.
insurance CnmPanyName: ifv
Policy#or Self-ins.Lie #:�'�6N�57u Z Expiration Date: D 6
Job Site Address: A 6t—le� City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the Polley number and expiration date).
Failure to settee coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ear as well as civil penalties in the form of a STOP WORK ORDER and a fine
or ono- �prisorunent
fine up $S1,.00adand/ Y
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded ro the Office of
Investigations of the DIA for insurance coverage verification.
I do yemby u r and penahies of pe►*7 that the Information provided above is true and correct
D C
S'
&#: l —2 ' —7�3
ne j
FB�o�ard
Do not wrke In th6 area,to be compktsd by city ormxw o el&L
PermitlUceme#
ity(circle one):
alth 2.Building Department 3.Cky/rown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.other
Phone#
Contact Person: :
1111V1111 ii ilVli fillK ill0 it tavf.lVilO
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
r
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the let representatives of a deceased euployer,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(muse
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a busmen or to construct buildings in the commonwean for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 15Z 125C(7)states"Neither the commonweal@►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 till out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s�addresses)and phone number(s)along with their certificate(s)of
insurance. limited Liability Companies(LLCM or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the aindaviL The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not tine Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 frill in the permidlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
own)."A copy of the affidavit that has been officially stamped or marked by the city or own may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or cominc cial venture
(ia a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax camber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26 OS www mass.gov/dia