2 GALLOWS HILL RD - BUILDING INSPECTION ✓A4
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SIMA 9Ef�Lfl rifD ." OVEO BY T*IE
,IA13=TbB Pi R . �1 .P T BfJNG GRANTED
r*{ CITY,,OF SALEMW ° . �.;
No. �/ Date i
M13 Tti
Is Property Located in 4 ' Location of
the Historic District? Yes_No xx n g..i�a < 2 Gallows. Hill Road
Is Property Located in
the.Conservation(Area? '' Yes No xx }
`BUILDING PERMIT APPLICATION FOR
Permit to ; „
.. 1 s
(Circle whichever apply) �, Roof; Reroof, Install :Sldln Construct Deck,` 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 �, am Denaro
Address & Phone 2 Gallows' Hill Road �? (978) <631 r6773, ,r,M t
Architect's Name n/a ,
Address & Phone n/a ( )
Mechanics Name':' Frank E. obey- ...
;tr trek' ^
Address & Phone 81 Centre Street, Lynn, "MA (781 ) '599-f353. r fi
What is the u p rpose of building? residence
Material of building? wobd 0 If a dwelling,for how many families?,a :1 '
Will building coMonn to law? vea Asbestos? no
Estimated cost $4,500.00` City License State Uceose p CS 027156
Aome Improvement
,r1 �
' Lic• 1103699 , u
Signature of Applicant .
SIGNED UNDER THE PENALTY
RJ
' DESCRIPTION OF WOR TO,BE ONE S 4 R°Y fir,;Z,4 ,' f
New vinyl` siding"" I"metal' �'6ers.
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MAIL PERMITTO: >
a 1;,
The Commonwealth of Massachusetts
'� Department of Industrial Accidents
Office of Investigations
600 Washington Street
k Boston, MA 01111
www.massgov/dia
\Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plutnbers
Applicant Information Please Print Le2iblv
'game (Business'OrppnizatiorJlndividual): Frank E. Obey, General Contractor
Address: 81 Centre Street
City/Stale/ZIp: Lynn MA 01905 Phone #: 781-599-1353
FAre you an employer? Check the appropriate box: Type of project (required):
a employer with 4 4. ❑ lam-a general contractor and 1 6. ❑ New conswction
ernployees (full and,or part-time).' have hired the sub-contractors� - listed on the attached sheet. t Remodeling
2 LiI am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8 ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
o workers' co ins
urance 5. ❑ We are a corporation and its
quired ] officers have exercised their 10.❑ Electrical repairs or additions
3 ❑ I am a homeowner doing all work right of exemption per %1GL 11 ❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12 ❑ Roof repairs
insurance required.] r employees. (No workers' 1313 thervinyl Siding
comp. insurance required.]
•P,ny apply a t that checks box#1 must also fill out the section below showing their workers'compensation policy info mizi ion.
' Honx:nwners who submit this affidavit indicating they arc doing all work and then hire outside amiracturs macs submit anew ulrida%'it tud¢at tng ruch.
Cunuacwrs that check this boA must enached an nddmonal sheet showing the name orihe subconttncbrts and then work cT'canq1.pobcy mf�1ntu+n1m
lam an employer that Ls providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: A.I.M. Mutual Insurance Company
Policy x or Self-ins Lic. # VWC 600461001 2002 000 Expiration Date 12/7/o7
Job Site Address 2 Gallows Hill Road Ciry/State/Zip: Salem, MA 01970
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 51.500 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 5_150 00 a da} against the violator. Be advised that a copy of this statemcnl map be forwarded w the Office of
In�estiga[ions of the DIA for insurance coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature /%� ��'`� Date 4/20/07
Phone A 781-599-1353
Ofcial use only. Do not write in this area,to be completed by city or town official
City or Town: PermiULicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/rown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information ana instructions
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 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 horse
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency sball 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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of is 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)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. I f 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 confurrtation of insurance coverage. Also be sure to sign and date the aMdavlt. 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. 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 bonom
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 permiulicense number which will be used as a reference number. in addition, an applicant
that must submit multiple permivlicense applications in any given year, need only submit one affidavit indicating current
l 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 was been officially stamped o;marked by the city or town may be provided to 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.e a dog license or permit to bum 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 number:
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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
T : f� � ""` � ,4(i,��j�. �, . � P•UBLI� P OPERTY`DEPARTMENT ;x ). tie( t�� �` �,
,:�: F • 13 ds f �s e �n t y n , R ;4tYr a P 44
N - � , n�; `f+�` > /.. c•eY2Ne�t^��Sk$ALEM'�MA�'O'1970 �`±'i a 5{Y'� ,i,.?�t .r"'`i uiM, �'� .
Aaq 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 III, S 150A.
The debris will be disposed of at: _19 cwamnarp t Road. Salem, MA 01970
Location of Facility
4/20/07
Signature of Permit A plicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
.Frank E. Obey
Name of Permit Applicant
Frank E. Obey, General Contractor
Firm Name, if any ,
81 Centre Street,. Lynn, MA 01905
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 pen-nits or licenses are to
indicate the location of the facility.