9 FREEDOM - BUILDING INSPECTIONr
�L�AIS1111UST-BE f4UE8--A%D A?PROVED BY T44E
II�SPFC .DB PaWfj TP A.PEMT BEING GRANTED
I \ CITY OF SALEM
Date \ 1
s�ia d
Is Properly Located In Location of�—��_--
the Historic District? Yes No V Building
Is Property Located In
the Conservation Area? Yea_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding Const upt Deck, Shed, Pool,
Repair/Replace, Other: L/Plyl yJ -
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 ANACL J � �5
Address & Phone PWaa MS) 7-'/SX11
Architect's Name
Address & Phone )
Mechanics Name GCS � "/NCI
Address & Phone r 01(a r-f lo
What is the purpose of building?
Material of building? If a dwelling, for how many families? Jn J
WIN building conform to law? Asbestos?
E ated cost ' (I�171 City License 0 N P' State Ucwm#CSZq 3i'/
�� Bone Improvement
1 Lie. i ss -
5 ature of Applicant
��� �� SIGNED UNDER THE PENALTY
OF PERJURY
DES ON OF WORK TO BE DONE
726 C&Z 06141S
MAIL PERMIT TO-
NO.
APPLICATION.FOR
PERMIT TO
LOCATION,.
E
PE MIT GRANTED
\ J
A17VfD
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rVECTOR OF B DINGS
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it
01 '31i2005 MON 15:09 FAX 978 745 9684 East Coast Properties
E 10 001i001
��GSPE�TY
V JEAS'1� A
Ji C OAST PROPERTIES
NATIONAL ASSOCIATION OF REALTONS•
I
: I January 31, 20D5
Fax (978) 740-9846
i
Thomas St. Pi.-rre, Building Inspector
City of Salem
120 Washington Street
Salem MA 01WO ;-
Re: Michael Strauss - 9 Freedom Hollow, Salem,MA.
Dear Mr. St. Pierre: r
Please be advi:lcd that Michael Strauss of 9 Freedom Hollow has received autholizatiora
from the Board of Trustees of the Village at Virmin Square Condominium Trust II to have
remodeling done in his condominitun twit.
The work will be Performed by ACH Construction, Inc., of 136 Parker Street,Maynard,
Massachusetts.
I If you need anything further, Please do not hesitate to call.
i
Very truly yotus,
EAST COAST PROPERTIES,Manager
VIL G AI'VINNIN SQUARE CONDOMINIUM TRUST II
i
BY:
d s
Cc: Mr. Michael ' du
i
I
REAL ESTATE AND PROPERTY MANAGEMENT
400 Highland Avenue,Suite 11 PhvOe: (978) 741.2003
Salem,MA 01970.1777 Fax: (978) 745-9684
6asMoartProO!seLcom
HN Vt1H3VN: Boardbt Building Regulations.and Standards,
O131AHIWl3 94 HOME IMPROVEMENT CONTRACTOR
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89£89 1.0 aN i=. t DAMES"BENINATI�
Gowan S
R ..: MOSInMf1S NOIlO(11LLSNOO i. 15 SMITH FIELD:TERRACE
SNOLLV1t1E)7M `t q �: NASHUA NH 03080 Admintstratorr
=3 The Commonwealth of Massachusetts
Department of Industrial Accidents
office oflnuestlgodons
F^ 600 Washington Street, 7 h Floor
Boston,Mass. 02111
— Workers'Com ensation Insurance Affidavit: Buildin lumbin Electrical Contractors
A licant iof/oyfm tion: - 6,Please PRINT I '•° _ y
name:
address: /J�Q,���'� nl� JN� /'')�(}�' A 2,/ C`,
city 4Y 0q state: ' • /r� nn zi : '0-1 hone(## '/ 5/g467 20
work site location full address): h2CC" ry Uj dY� 4
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole nroorietor and have no one working in an ca acit . ❑Building Addition
I am an employer providing workers'compensation for my employees working on this jobl
company name: ETCH (_F' 4—wag C 101Y. -TIVC ;«
address.'
plum #
insuranceco. 04# .0 32632.
❑ 1 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;
city: phone#• �.
insurance co. policX,# '
company name:
address: '4 ' u
city: ++r M
s
insurance co. �mii�ey#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penafties of perjury that the information provided above is true and correct.
Signature - GtM?�� Date 115,
l
Print name ME.5 E-NINA—T( —Phone# 1-3 Zy
r0rho
use only do not write in this area to be completed by city or town official
town: permit/license# ❑Building Department
❑Licensing Board
ck if immediate response is required ❑Selectmen's Office
❑Health Department
person: phone#; ❑Other
OPi.2an1)
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 local licensing agency shall withhold 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
affidavit should be returned to the city or town that the application for the permit or license is
date the affidavit. The a ty pp
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 reference number. 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.
' iT` $ ',.... ��'e49k'C'+LG..'h A3�yr � .� ✓ [ •[
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of lnuesflOadons
600 Washington Street,7th Floor
Boston, Ma. 021I t
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
�o CITY OF SALEM9 MASSACHUSETTS
® PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
�a 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.
The debris will be disposed of at: i L6a440✓
Location of Facility I
*nature of Permit Applicant Dat
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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A1/dimension size designations given are lltis is en original design end must not be Designed:7/23/20�
subject to verification on job site end 20 �`••' released or co ied unless a livable fee has Printed: 11/22/200
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edjushnent to fit job condition. P,J. barn paid or job order paced.