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20 FEDERAL ST - BUILDING INSPECTION (2) 1 -pj MMWT*Ef KAW4640 APPROVED BY T44E PRW TDA.PEAIf EEING GRANTED CITY OF_SALEM No. DAM Is PMWW Locftd in Location of Mx4"a is ? Yft�No_ DWALM a wovny LooWd in - m Gona�nMlpn Awa? Yct_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Rerod, In" SWta Cor>tmkt Deck, Shed, POW, Rapau/Raplaoa, Other• r E,rJOV� PLEASE FILL OUT L UMY i COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersowd hereby applies for a permit to build according to the following spoodicabonc Owners Name Address & Phone U f Fd�P / si r&r 7 (91A. -9 V-le)gi e Architect's Name Address A Phone J 1 Mechanics Name S771lyl c ii Srvxi Address & Phone IW410 iD.0 lid 5-35�- wht is aw purpaa da�lwn07 �yirio dF� �`i TP f/E/�/ Sii✓��F ,�i�ii/i rwdc-- UAW"ofb~ A)1)1)d a omov,for tow many Won? wo bAWp conform to law? S/,FS Mbmu? A/ri✓C EdW Wil d cW �L'T qly Lbws a N O` SUM um" �m f Applicent SONED UNDER THE PENALTY OF PERJURY DESCRRIlFno I OF WORK TO BE DONE �i-,E,dlAc ,� �i TC/`�i✓ C,�Bi.r�Frs ��r FN a ✓;�rC � �1��r� MAIL PERMIT TO: No. APPLICATION FOR PERtlR TO LOCATION PERMITGRANTED 2.0 APP0G / Paz INSPECTOR OF BUILDINGS F The Commonwealth of Massachusetts Department of Industrial Accidents Ofisce of Investigations 600 Washington Street Boston,MA 02111 www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elep a pal Lehi mbers ull Applicant Information Name QkdocssA0rpoizati0n/IndividA: illy iTf� �A�1�tNTf� Address: /�Vq A0/O R/ Ad City/StatelZip: c lid/ (/, 9 Pel hone# Are you an employer?Check the appropriate bit:: r7. Pe of Protect(required): 1.❑ I am a employe with 4. �] I am a general contractor and I New construction employees(fall and/or part-timc).• have hired the sub-contractors QIRemodelmglisted on the attached sheet=2.[ I am a sole proprietor or partner- These sub oontrauors have ❑ Demolition ship and have>b emploYeea workers' comp. insurance C3 Budding addition working forme in any capacity. (No workers' comp. insurance 5• We are a corporation and its officers have exercised their lo.❑ Electrical repairs or additions required-1 110 Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL c. 152,§1(4),and we have no 12.[] Roof repairs myself e r workers comp• bees. o workers' insurance required-]t comp.employees. requiredl 13.0 Other. 'Any applicent ilea cbecks box pl moat am fin out ale section below sbowmg their worker'conven atiouPoliq infomrtion: en doing all work and glen bite outside contractor must subneit a new affidavit indicating such t Homeowners,who MAMA this ost ait indicating they the nuns of the subcontractors end tle'm wotkm'con4•policy information. :Cwtracoor that check thin box m neoat attached®additional sheet slowing . I am an employer that is providhtg workers'compensadon insurance for my employees. Below Is the policy and job she Informatiar. Insurance Company Name: Policy#or Self-ins.Lia#: Expiration Date: Job Site Address: City/StatePLip: 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 ce under the pains and pe of pe►wy that the information provided above it dot and eorrecit S ' D Phone# �/ 7d' J 3 S� 5 31 Y - rlduset Do and write i»thb area,to be completed by cloy a town o,84rtaL PermWUcense# ity(circle one): alth t.Building Department 3. con* Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Coatad Person: Phone#• f�� 1111V1 AAA"%,1Vll Nll%.a JLAAIJ6R 1a%r6A%FAA0 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 hue, express or implied,oral or written." 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 legal representatives of a deceased employer,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 employa." 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 business or to construct buildings in the commoneakh for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth 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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)namc(s),addresses)and phone number(s)along with their catificate(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 affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidens. 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 fill in the per irMcente number which will be used as a reference number. In addition,an applicant that must submit multiple permi"cense 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 town)."A copy of the affidavit that has been officially stamped or marked b the or town be provided to Y �Y nY Pro 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 commercial venture (i.a 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 numbs: 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 5-26-05 www.mass.gov/dia o 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: SH/EU' 11tWx)jC a)461-E (Location of Facility) SA/Giyl. Signature of pplicant Ilyenl Date ��+e-n. r Wt'P`Pm � rr' 4lT s?^t•'M"'{s15+`.�'�t� ,"' � �.� ^psi .r;....� i'y� E `§, f(. ��'*i ` • �4iyl •� 5 1! � .—mac • � � :�)�'�� 44i� ' 111 'I{ ft I �r EW �.�'MM �� nF�n f1� k ,(02 e 40Prttiz INS IS IINNIMMN MON \1 R ' �Y n N& r 1 m, yN IMP NEWMA 'H'25i r ' . .� F:I1 T � low Note;All dimensions gi. Jul ven verification and adjustment to fi '". : i � .� �� represent -1V � _ f i sale: date: ...... .............. Page. ......- NAT+) rer ..Yoek„AtWoa D391LR .--- -- - -..-5 Hilltop Drive.York,.Maine a39D9._ Ann�2WI697 Copyright O Architectural Planners, designed by— ---.—.SaL8QO-2.79_169LFuc9oo.27g "-.___...www.arLhiteatYrai lann•ri Copyright O Kitchmplaro. -----_---- Note:All dimensions given are subject to job site Ham; Structural details others. Note; Perspective drawings represent the artist's interpretation of the general verification and adjustment to St:job site conditions appearance of the room and are not intended to be a precise depiction. The first 3tCP in the design er,ocess...see it before you. begin ) . r i j} i S 1' .3 s sine:/2 e _ ! , r P+9e' rev: Tel gag-279-166n F., y�� .___ ..__S.Hilltop..Drive,.Yark,,.AAaina 03909_.. "'' Copyright O Architectural Planners, designed byl✓ry ..__ _Sit.9.Q0a2Zfl 164Z_Ean_flQ0:2Zfl-1697 _.__..www.architacturalplannses cutn_----.._. ----.-___- Copyright O kitchenplans. _---WWWJdtch4n 61 Leaae....__----. ... Note: All dimensions given are subject to job site Nam; Structural details b others. Note: Perspective drawings npressat tha artist's interpretation of the general verification and adjustment to fit;lob site conditions y appearance of the room and are not intended to be a precise depiction. The first step in the desi n process.. .see it before you begin ! i 1 r r I J34T AdIkI� < ,P s: I la� e pg �.wPIP�IFiP1M' "y� date: ' pager u h _.--5_liltltop_Drive.York Anins.:033,494__. � 5-Hilltop-Drive,-York,Mains.-03909_ _ Copyright O Architectural Pl�nnerc. deigned _ _._TdBOC:2Zg-1fs9LFaa900 279 ifi9Z _-. Copyright O Kitchen plans. _. --._-rauw.kltah IaALCM._..._._..PY►� Pl �P N Note:All dimensions given ars.iubjhct to job site Neu; Structural details by others. Note: Perspective drawings represent the artist's interpretation of the general verification and adjustment to•f o ; rucura jj, li sib conditions. appearance of the room and are not intended to be a precise depiction. Thesfi:rst step in the design pracesi..-.see it before you begin-I