22 BUTLER ST - BPA-2006-412 fL-MS* r-0E fIL£B4AG APPROVED BY T44E
IW,,EC=PRIQR TD A.PEBF BANG GRANTED
J �j CITY OF_SALEM
No. 12-6 / \ Dale
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof 4pQ. f Install Siding, Construct DecK Shed, Pool,
spaidReplace.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS N 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 S(-.L.\
0197�
Architect's Name
Address & Phone
Mechanics Name
Address & Phone y5 1 n �1• � 1 �1 .�-�L9�� 7-��� �LSs
os�z
whet is tfw pwposa of WHdW
M"w of bulldirq? n a dws q,for hm many lamas?
WO bxrYdirq conform to law? Asbsatos?
EalYnat I Z r�. Clly LIMM r N A SUM ■ 0t rge3
/ Rome Lmpro t
Lie. f 1 ZR7-)' .
"biu of Wicant
SO4W UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
l/(J S71v�/hr,.al Glti 4..��
MAIL PERMIT TO: ®w�`
No. /2
APPLICATION FOR
PERWT T11O``
RBn
LOCATION
Ile
PERMIT GRANTED
7/0 �T- 20
ova
INSPECT F BUILDINGS LL
z
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal 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:
Jrc (Location of Facility)
ignature of Applicant
lL9/a5-A
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (A)', -f Please Print Legibly
Name (Busin`esss/organization/Indivlidual): pe °`/I q Vt ' $ a'� ` DOar-S
Address: 7 S Furl ce 1 .
City/State/Zip: tle A't11 Phone#: 97887265*-726S
Are you an employer? Check the appropriate box: Type of project(required):
1.X I am a employer with 2°5 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheer t ❑ 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 ME] 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, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.[1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who subunit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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. 1 -_�J
Insurance Company Name: }}ear—} A>rK �nS urtit�►Ge � Rr��
Policy#or Self-ins. Lic. #: 08 bl GA/L S 7y I Expiration Date: -7 1> O(�
Job Site Address: — - Cu 4 ler 5+ • 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 $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 ains d penalties ofperjury that the information provided above is true and correct
Signaturef p Date: L 6 z 5
Phone#: / 6S -72SS
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#:
Y �SLJ
BOARD OF BUILDING REGULATIONS
z License: CONSTRUCTION SUPERVISOR
Number: CS 089839
,p Birthdate: 06/19/1972
Expires: 06/19/2008 Tr.no: 89839
Restricted: 00
SCOTT P HOUSE
854 EROADWAY 0 G�
HAVERHILL, MA 01832
Commissioner
' � J� �Om/h2MitlTBRG[/L o�✓r�radow.'�u�4P,C�d
Board of Building Regul :isns and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 129774
Expiration: 11/212005
Type: Supplement Card
PELLA WINDOWS AND DOORS
SCOTT HOUSE
45 FOND[RD.
HAVERHILL,MA 01832 Administrator
NUMBER DRIVER'S LICENSE
S69694966 .a
DATE OF BIRTH CLASS REST HEIGHT SEX
06.19.1972 D 6-00 M
EARRES
06-19-2006 b.
HOUSE
SCOTTP
854 BROADWAY
APT#1 oclslEn '"',
HAVERHILL,MA
01832 �Q(,,,v ..