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21 GALLOWS HILL RD - BUILDING INSPECTION �L MSiNl16T�EfILF-� APPROVED BY T44E .Il>ISPZCJDB PIER T I.A.PERMAT BEING GRANTED CITY OF SALEM << N�Jy�4� Date �JJ is Property Located In Location of 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 eroof, Install Siding, Construct Deck, Shed, Pool, epair/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: ^111f1 Owner's Name �il /�/�//i S / 4441o0Ipci Address & Phone Architect's Name Address & Phone L Mechanics Name s Address & Phone What is to purpose of building? Material of building? If a dwelling,for how many families? Will building conform to law? Asbestos? Estimated cod dowigo City License • N ", state License 8 7/ SQC61 Nome Improvement Lic\\ ll . 66 ' r ignature of A licant V V SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO/BE DONE all ' � ff/I N , Xo 6/:7 fits c// � e`qo MAIL PERMIT TO: � �� �� No. APPLICATION FOR PERMIT TO �e-—,oP� LOCATION 2/ �s¢lCd'Ii1S �LG k'IJ _ PERMIT GRANTED APPROV Dp G S ECTOR OF BUILDINGS s The Commonwealth of Massachusetts _ Department of Industrial Accidents giftsstimesdoadens 600 Washington Street, a Floor Boston,Mass. 02111 Workers'Com easation Insurance Affidavit: Buildin lumbin lectrical Contractors Nal ad r"7 ,y.s� -I L � r— city )/'� lce/1 state, / /�/ zinc C,'J�Qohonc# ec; work site location(full addressl� ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction model ❑ 1 am a sole proprietor and have no one working m any capacity. ❑Building Addition -- ----- —M-7gfFan employer Mviding workers'-em nsat' n-for my emplovees working on thisjob sr„'n' • ,� w, yx"�i' C ,r'vf�, �ell K I�am�a oreproprietor, eneral o tea tor,or homeowner circle one and have hired the contractorsT� � f � ❑ g ( ) listed below who have J the following workers' compensation polices: mmmov name- address: . re� 4 6 ts' .<; E 4 i•K ux ,1 x+"s;F i� e r .?t z� �'2 e; ws .. 44,­ co�ay name: address: ^�'a' ..✓ha' .G wx y., n4he} 2 t In k r, c '7771, .� �4-.kSrA.E:. q Ji= L ».+•!✓Cl r�a ?.� . -�t ...y.. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a not up tosi,500.00 and/or of MGM one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine MGMa day against me. I understand that a copy of this statement may be forwarded to the Office of m fig us of the DIA for coverage verification. 00 t do hereby certify under the pains d p /ties of rj lhar the infortnation provided above is true and corre Signature Date a s�6 Print name Phone# '— official use only do not write in this area to be completed by city or town official city or town: permit/license a ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Halth Department contact person: phone a; ❑Other I rerised Sept Nxnl 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 oocal bceusfng agency shairwithfiotd-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. ... r Applicants tel b checking the box that applies to your situa tion. Please affidavit completely, g PP Please fill m the workers compensation p Y. Y 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`uumber. The affidavits may be'retumed 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 Omce tllnllemoadens 600 Washington Street,7t°Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 . 0 2 CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1. SALEM, MA O 1970 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 Pennif#F , alk debris-resulting-from the-contraction-activity— ---- -. governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c a S 150A. The debris will be disposed of at: IV S " ///, 7 Location of Fac' ' Signature of Peluirt Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any rw 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 cIll, S 150A, and the building permits or licenses are to indicate the location of the facility.