9 COTTAGE ST - BUILDING PERMIT APP lftVmoW*E{K*WAND APMOVED BY T*E
1dSP.9=0 PGIOR 7D A P.E114W AOM GRANTED
CITY OF_SALEM
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BIALDING PERWT AP14"TION FOR:
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PLEASE FILL OUr LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
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TO THE INSPECTOR OF BIN' NM-
The urldarowsci hereby applies for a pent to build a000r ft to the blW*np
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Ownors Name
Arddteds Name
Address & Phone j 1
Mechanics Name - ,
Address & Phorw -t/a%ZC€5?fK � � �-5-766
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BMW M=THE PENALTY
OF PMUURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT
0,1E74
No.
APPLICATION FOR
PEW I TO
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PERMIT GRANTED
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APPM
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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: /��
(Location o Facility)
Signature of Applicant
Date
�I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Sired
Boston,MA 02111
wwmatassgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electiidans/Plumbers
Applicant Information Please Print Legibly
Name(Business/organization/Indiviidual): I-� onnF :FpDT _
Address: sr, -
City/State/Zip: Phone#: R �) �_ J5-19q ' 5 7
Are you an employer?Check the-appropriate box: Type of project(required):
1.® I am a employer with t() _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/orpart-time).* have hired the sub-contractors
2.❑ lam a sole proprietor or partner- . listed on the attached sheet. t 7. Qx Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. work' comp.assurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
requinA] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.[] Phtmbing repairs or additions
myself. [No workers' comp. a 152,§1(4),and we have no 12.[] Roof
insurance required.] t employees. [No workers' 13.E] Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their worlm'boa polio mfommtim
Homeowners who subunit this affidavit indicating they we doing all work and then hire outside coahadrns must aabntit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name ofthe subcontractms and their wotkas'eotip.policy information
am an employer that Is providing workers compensation insurance for my employees. Below&thepolky andjob site
formation.
wmance Company Name: —
olicy#or Self-in.Lic.#: "7 g R ( {7 I Expiration Date:
>b Site Address: City/State/Zip:
ttach a copy of the workers' compensation policy declaration page(,showing the policy number and expiration date).
enure to segue coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
Fup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
tvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains
�and penalties ofpedivy that the information provided above is true and correct
¢nature• �i,� l /�.VLArtr4a Date:
rime#• q-) S— G79 q ' t3 C(9 &
O,fcial use only. Do not write in thin area,to be completed by so or Own ofikiai
City or Town: Per mitucense#
leaning Authority(circle one):
L Board of Health 2.Building Department 3.Cky/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: