20 BECKET ST - BPA-2006-329 SIDING -a�-osr
Citp of �&al*e 7t, �Kaejejarbu5ett5
Q PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED , �i
Location of Building '_0 eE E-"-
Building Permit Application For.
'(Circle whichever applies) Roof, Remo install Sidin onstmct Dock, Shed, Pool
Addition, Alterauon rr/Replace,Foundation Only, Wrecking
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 rding to the following specifications:
Ownert Name: L aGC�iQ Cooutra r.. / /o m e-
Street". 0 6£c k!E City citygGc�4��e
State Phone 67) 7yy— v 7`/R State Ph j /-57(1P
Architect: City of Salem Lic#1
Street City State Lid# KW#
State Phone ( ) Homeowners Exempt Form_-yes Y,._no
Structure: (please circle) Single Family. Multi Family# Other
Estimated Cost of jobs r 7i U on
Will building confirm to law'--iK-ycs no
Asbertos'_yesXno
Description of worst to be done::
�lrly H�u�,�co
Drawiafj Submitted: es_Y, no Mail Permit to:g .(/ �� t2 '
X -V,7-,1 560;ed, /
Signature of Application,S GNED U DER THE PENALTY OF PERJURY
CONSTRUCTION TO B OMPLETED WITHIN SIX(6)MONTOS OF PERMIT ISSUED DATE
Department use only: PemJE'# .. Zoning Maput
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CITY;, OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
04& 120 WASHINGTON STREET, 3Ro FLOOR
a . SALEM. MA 01970^-.-... -
TEL. (978)745-9595 EXT. 380
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acimowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A
The debris will be disposed of at: 4-)I{rJ G 99 IV t )OUl, 1 F WOQ C?5't C 2
Location of Facility
CAN
Signature ofPermi App cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
� � 5 r�(�lE�tvw6y� Si , U�o2C�5ff�
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 c1II, S150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts z
Department of Industrial Accidents ryaL
j ,
Office of Investigations n:
600 Washington Street
1 Boston, MA 02111
7t t
wwx.mass.gov/dia t f•`
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letnbly c>
Home I)epot
Name (Business/Organization/Individual): 345 Greenwood Street ^
Worcester,MA 01607
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required)
1.® I am a employer with-S� 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t Z. '@ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §I(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
"Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information) - - - -
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such - -
tContractors that check this box must attached an additional sheet showing the time of the sub•coniractors and their workers'comp.policy information:
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: Z66 O • G%
Policy#or Self-ins. Lic. #: ' 6 99 ;e 72 Expiration Date: —0 G
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpena/ties ofperjury that the information provided above is true and correct
Signature: ,�� Date:
Phone#: 01 7C S__ 0 k,
Official use only. Do not write in this area,to be completed by city or town official:
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#: