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8 FREEMAN RD - BUILDING INSPECTION -Pt-AM IN"ST- E ffLf� APMOVED By T*IE ,LWF.GTLaR PFIICIA TP A.PFJ3MT BfJNG GRANTED CITY OF SALEM No. — J ��: Date s.pp �`wMIX6�y Is Property Located in Location of P., the Historic District? Yes_No BuildingVI r" Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Ro , Reroof, Install idin Construct Shed, Pool, Repair/Replace, 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,� 05 —TZ Ire") - Address & Phone V513 A Address & Phone ( 1 Mechanics Name Address & Phone ( 1 What is the purpose of building? sL �oL Material of building? If a dwelling,for how many families? Will building conform to law? Asbestos? It/o Estlmated co4�001 COCO License # N A stat n Bose Improvement Sig atur /` Lie. Ir e of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE /?zoyast r�✓1n �g� Vz jk1r:t,.cLe c tD 55/1�115 2"( I L ADD Z tz/Ok 5�e,l Do2Nte.� f�17� A/� I `/� sc l� �r:il p �,,.,i�u V•�/N f S i o;,Y� r �P ra-,r MAIL PERMIT TO: � 't No\1\ V APPLICATION FOR PERMIT ff TO nn,����iyl(9Lrr'an �^mot' - brims$2LC LOCATION � p PERMIT/ GRANTED /Wo L� AP G/O/VFD At viiti, INSPECTOR F BUILDINGS r rY/LIG r�r��r IwYPANUW OM.vI , ampuO M�O�MAOt�O T46��rMNM.it0 STAILir�l .�. a.. - - t- Df OMQ�AMMM 5 seead�.oswl�rpaRr R--onms rq U41 .ems r aGum a ds�orsr�� ice,.. s..rmow:d= 1i'"wr 1��DsO���iiM I�wi dl..papM�r/os.�s/�Mars �Mti1*Oft=aft"Yq ash soft aW+wrwrc�u� . N= A~ 73sstiowswtu d So. .M..k.di.�sr M.aw be 6. isAdownddw IeeWaidis dltll.JK sr pop-. 0-1� The Commonwealth of Massachusetts Department of Industrial Accidents F office ellmesugamens 600 Washington Street, 7ih Floor Boston,Mass. 02111 Workers' Compenssaation Insurance Affidavit. Buildin lumbin Electrical Contractors _ "Applicant information. �.g� � � T-sv, � .mom--Bleaso PRINT leeibiv"r r. 4 ,«n` �. � u name: I I �C4 �'v/ '+N5 '�' mAAq� /f 4.,,� �iGnnw address: k4 / • ����// city ,csgze, state: ,04- zip� ohone*✓s20 V7y- work site location(full address): ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ 1 am a sole proprietor and have no one working in any capacity. ❑ Building Addition ❑ I am an employer providing workers' compensation for my employees working on this job. eomoanv name: address: } city: - t, ohone#:'' y`. �'. -� insurenceco. li # F am a sole proprietor,general contracto 0 ow trc one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: City: - phone#: insu ranc co. oli # - - ; is eomoanv name: " v address: , a' U t I city ohone#• 'a :'° 6 insurance ca. oli # �• � (' `Apach-.additiomi 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 cer f under th painnssand pen ' ajperjury that the information provided above is true and correct. t� Signature � �/�` Date / y-��(lJ ,a / Print name / r1O r` r,a �� Phone#( 770 L`7f' L/- official use only do not wrote in this area to be completed by city or town official city or town: sz- /'2M yta4 permit/license# Pd Building Department ❑Licensing Board ❑check if immediate response is required []Selectmen's Office []Health Department contact person: phone#; ❑Other Irc1"ised S,1 30031 -- 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 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 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 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 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. _ 7 ;. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7'h Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 a ' o Irg a° c✓�� AS r� tl°01 i 2 7 OH%1 }SeL yy� � gip' � as z��J w, '7+0„Z£ sa�4 )1�.,� „ ? -- - - � - _ � r + _ L -r- '- --_ r _._ _r � }.t __+•--+--+-._- -.....L 1• . .. «. +-. .� _}-. +- .�..�. a r- _ _ .._ ..___ .�_ __� _ ..__* _�._+.. + - - ..� -«_ } _fit .—_:- __, _..___.. � � -�- � . .._. _._ _ . -,- . r T r. r _. ._ r -_ - ..- . _ _ . � .-. .. _. .. ..- __ i �. _ _ _. I ' +� k" / � .. .t. .,- _ .. � + ... .. r +.. T r r. . � ♦ L _ . - - +-_. _. - r r . _. T + - - - T + + - � +_ . r _ Y i ' -r- i - . .« .Y. -4 . -� . � «. Y. .- i v Y � . -L {. 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NVLL 0 4 h v o � /ZR 1 • I, Christopher R. Mello, A Registered Land .Surveyor, Do Hereby Certify That The Above Mortgage Inspection Plot Plan Was, Prepared For Xrl i54Z1 //rIG Z&'Le Zv In Connection With A New Mortgage And Is Not Intended Or Represented To Be A Lan Or Property Line Survey. No Corners Were Set. It Cannot Be Used For Establishing Fence, Hedge Or Building Lines. No Responsibility Is Extended Herein To The Land Owner Or Occupant. This Plan Shall Not Be Accepted For Recording. The Location Of The Structures As- Shown Hereon This Plan Has Been Prepared For Is In Compliance With The Local Applicable Conveyancing Purposes Only For The Zoning By-Laws In Effect When Constructed Above Pa rty And With Respect To Horizontal Dimensional Y Is Not To Be Used Requirements Or Chapter 481 Of 1987. For Boundary Measurements. Subject Property Is Located In f Zone Qr A Federal Insurance stration !Desi.gnated to4d i - „Hazard Area, As Per Map5(A �JZ SCALE: MELLO 1?Dated 'Na,,37.317 pi.' ^ _� DATE: 237 PGr1 n , a REFERENCE: �� BK i. Su s" I y.