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7 FREEDOM - BUILDING INSPECTION Y -PL*M IMST-eE ffLE� APPROVED BY T*IE &SP XTL1R ,PFWR TD A PERMIT R,EING GRANTED ,\\cc CITY OF SALEM V ) Ott No. \ Date :.3/ � Nit. Is Property Located in Location f t the Historic District? Yes_No_ Building Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Rero f Install Siding, Construct Deck, Shed, Pool, Repair a lace 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 & c 4-Ykr 614jU/tw Q Address & Phone 7 f✓-,re 6q, / i//"j Slew (�7A 5-9q- 030(o Architect's Name )!- Address & Phone Mechanics Name /�P its ��/✓�tif4�� Address & Phone a9-3 CPO±v G A (9) 97/ • C. 73 8' What is the purpose of building? Material Material of building? IL,act' `"v< If a dwelling, for how many families? Nil building conform to law?1'eS Asbestos? Al O Estimated cost 4 9, OAS City License n N A State' � n # ��fC/S 3 Z— Home Improvement !G( CALK Lic. / //� 3 �V1 (4 — Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE RpoIUC< J,36c , jLp c6ck- 54-re � � ��Cs uu ;4, /N r Cr 6 (�F ��PI I T4k4 Je /OCe-A-I-Jot� l t44 (( 4 I I ) M%j Vo/ %i n�{ NnCKO� S 1 . I�0 S nw v� t t..r"k . /l MAIL PERMIT TO: Pi44n ►+a0 "-�V�t htd 5+ No. APPLICATION FOR P\ERM TO LOCATION PERMIT GRANTED 3hr)��- 2.0 APPROVED 4� INSPECTOR OF BUILDINGS The Commonwealth of Massachusetts Department of Industrial Accidents ,r - BIflCeO//mrestlgetlo9S 600 Washington Street, 7tb Floor Boston,Mass. 02111 Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors 4 111 a name: address: city 6 �p�t'�vG✓r s state, zip 0/1f� phone# 4�' � 7 7 3r� work site location(full address), ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ 1 am a sole prop rictoi and have no one working any capacity. ❑Building Addition 1-am an em to er rovtdm workers'--com - — ------ - - _--- P Y P g pensauon-formy employeesworkin o thtsjob r«� r�/[�'� /r� ��j) /J `��r^" 3 s •. .t Y"S` r ' t A� company Dome: T{J•• LSL/�f / '� ", ,"..�'{' n Sf ad yt iA�dP" �ta�,.'.r -` i'tl'a.{ ,>. tXr - k address. r / — pity: (��c Yt " j12¢ c ab< d n pirena->ti % 7t7 r`7� G 27 —r--r—�--. .� insane«sadlam it ea (.F ' `''�f-• J,4-�-- - ate, �a7y4L ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: Company name: address: , -^Pr'. _ ,S.J }mc. +y' + £ F' in uran 41 Its Compaq v name:.. address: atr x _ 'Sy' 4 In8 'd gal policy Failure to secure coverage m required under Section 25A of MCL 152 Can lad to the Imposition oferiminal penahla of tine up to s1,500.00 and/or one years'imprisonment a well as civil penalties in the form ofa STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a COPY of this statement maybe forwarded to the Office of Investigations of the [Afar coverage verificatioo. I do hereby certify der the pat rid p !' in ry the ormation provided above is true and rre ,/ � Signature Date �c 31 � r7 Print name dy�D Phone# % 7� 77/ L ly do not write in this area to be completed by city or town omcial Permit/license a ❑Building Department ❑Licensing Boardmediate response is required ❑Selectmen's Office n: hone#; ❑Hallh Department t F ❑Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,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 ajoint 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or focal licensing steucy shalfwithhold the-issuance-or— renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 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. City or Towns 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 permit/license number which will be used as a referenceWnu`mber. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents 0((Ice et Imlestl9etlelle 600 Washington Street,7 s Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR h SALEM, MA 01 970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge 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/I�II, S 150A. �d"2 The debris will be disposed of at: �� Location of Facility A � &,�� / .7 " US-_ Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any 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 cUl, S150A, and the building permits or licenses are to indicate the location of the facility. ci . t GJG �n2 y9� / BOARD OPeu1CDW(;AUP LnrwI'*license: CONSTRUCT1614RVt , E i Number CS 056432 n i ` Sirthdate i0t&3t119§2 Expiros 0813ff2'Q04 Tr.no: 348 ._- - � tZestricteit t_G KEITH,A 253 CENTRAL.STO ALD` GEORGETOWN, MA`p1.g33 Administrator i Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 111834 Expiration: y4_12_ 05 Type: DBA KEITH MACDONALD CARPENTER/WOODWORK KEITH MacDONALD ` 253 CENTRAL ST GEORGETOWN. MA 01833 Administrator 1