9 HATHORNE ST - BUILDING INSPECTION ft,>AIN6IMW*EfK0104M1D &PPROVED BY T414E
Jdsp==PWI TDA PERMIT All" GRANTED
CITY OF SALEM
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BIIILOING PERMIT APPLICATION POR:
Pwmk tm
(Groh whWmww apply) Roof, R roof. nmg Siding, Coratnlot DUK Shed, Pool.
Rep her'.,
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undo M rad hereby applies for a pormit to build ao w ft to Ow folbwinp
speoftaow&.
Owrwr'a Name
Addrw& Phone 7
MCfliteas Nww
Addrou & PtwM j 1
Medanim Name ► H�
Address& Phone � 0c 2cFs T �i7�j 5&,Ct-S-7
Not is Mw puq o it buMrkp? S ,rfy ►.. z A c_
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SIGNED UNDER TILE PENALTY
OFPmum
DESCRIPrM OF WORK TO BE DONE
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MAIL PERMIT T0: ell)
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NO. /0
APPLICATION FOR
PE l TO
LOCATION
PERMIT GRANTED
2.0
4
INSPECTOR OF E U LDOM
^� The Commonwealth of M(IssrtcImsetts
Department of 11u111strial Accitlents
Office of Lrvestigtttions
600 fi'rrslringtan Street
Boston, MA 02111
rotutc.mnss.;ovRlirr
'Workers' Compensation Insurance Affidavit: Buil(lers/Contractors/Electricians/Plumbers
1,licant Information Please Print Legiblv
Name Rom
Address:Cite/State/Zip: JA).R'rV`G i f:2 Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
I I am a employer with � ❑ I am a general contractor and I
employees (full and/or part-time)." have hired the sub-contractors 6. New construction
❑ I am a sole proprietor or partner- listed on the attached sheet. I ? ® Remodeling
shin and have no employees 'these sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No %porkers• comp. insurance, 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] employees. [No workers'
COMP. insurance required.] I10 Other
>nc applicmn that checks box a 1 must also fill out the section below showin,their workers compensation police information.
t Flnmcoa-hers Mlo submit this anidnmh indicating they are doing all work and then hire outside contractors must submit a nee%,affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the suh-contractors and their workers'comp.policy information.
/run an employer their is providing workers'compensation insurance fir my employees. Below is the policy and job site
information. n
Insurance Company Name:
Polic. it or Self-ills. Lic. #: S 9 y?9 Expiration Date:
.Job Site Address: City/State/Zip:
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
tine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do herehy cerrify lifider the pains anal a lalties of perjury that the information provided above is true and correct.
Date:
Phone
Official use only. Do not write in this area, to be completed bl, cm, f town afficirit.
Cite or Too n: Pel Itili icense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CIt\'/Tosvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone Contact Persau: n:
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
3 u 5 (�'-Yc �vcoa S , LAD CttCe$=,-'S&
(Location of Facility)
Signature of Applicant
2-
Date