100 HIGHLAND AVE - BUILDING INSPECTION (2) IM--*M4AUST-BE fiLf� APPROVED By T44E
,II,t�S,PFCTDB PPMR TD.A.PEAMIT BfJ: VG GRANTED
CITY OF SALEM �7
Date
Is Property Located in Location of
the Historic District? Yes No Building 166
Is Property Located in
the Conservation Area? Yes_N
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidin Construct Deck, Shed, Pool,
Repair/Replace, Other: �% �tA nz�
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:
Owners Name
Address & Phone \ L 1
Architect's Name 'La''�
Address & Phone
Mechanics Name
Address & Phone
What is the purpose of building`?
Material of building? (31-rnele If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost X )'o O 0 Ctiy License • il k State License 8
Baine laproveaeat
Lic. /
-Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
toyo'j-4rrr
MAIL PERMIT TO:
No. —V�
APPLICATION FOR
PERMIT TO
LOCATION ',
/OD —y1.� 3
PERMIT GRANTED
A7ROVfD
INSPECTOR OF BUILDINGS
. f
I
i
o CITY OF SALEM9 MASSACHUSETTS
i PUBLIC PROPERTY DEPARTMENT
• a
120 WASHINGTON STREET, 3RD FLOOR
1 SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. LISOVICZ, 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 di ed of at: %0a
,
TLocation of Facility
i es'
ignature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
/6 o%�7a
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.
1
i
i The Commonwealth of Massachusetts
7 Department of Industrial Accidents
�� `-' - 0�0/ht�estlgatlOaS
-= 600 Washington Street, 7`a Floor
� Boston,Mass. 02111 ycv.
2,
Workers Cit ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
address
/
cif state: �/J O `Y 7 Q hone# ���7/-6 66 o
work site location(full address): G r ��� 17�- G
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction emodel
❑ I am a sole ro rietor and have no one working in any capacity. ❑Building Addition
- -- - -- - I-am an employer providing wor ers'-compensaton-for my-employees working on this lob — -
copativ"Rine: �er�- fr('+ �m m
addrem Itwmn
-6
L.
❑ I 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* - -
r
address:
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a v.- . Wi 'a '{4 } +15 m qi.. 'e.sAT 1 M v';�F�i'Y� t '�d ✓� d. kr �"4✓�'r'.ii'+V}"�
ins ranee co. �M
'R't Palley Y #.r v.,•'fitiE r d 5. ,m+js,s ..¢iry r *1 n."-�+.
lima
Company name:
M r .
address: - - 7`,jT'xr"t''k r r *,#dry ° y' 4�}
p
ll!I
e
v` �+.,w•y .r-1.rt" •.•.�....r+e. .•w.e�ei.i+.nv/a - ` +."'w"...�rr:"Ta�
n ..- v.h M £ . § {rck Ka 4iaer�c..0. a.n,.e ._�. .-iha ^✓ R, x..-�
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 S1,500.00 and/or
one yean'imprisonment as well ascliv!Lptuddes in the form of a STOP WORK ORDER and a line of$100.00 a day against me. 1 undentand[bat a
copy of this statement may be fo to the Office of Investigations of the DIA for coverage verification.
l do hereby certify un pa' a�fperjury that the information provided above is true and correct.
r
Signatu Daze
Print name -,, Nw Phone
T
omcial use only do not write in this area to be completed by city or town official
city or town: permit/license#
❑Building Department
[]Licensing Board
❑check if immediate response is required ❑Selectmen's Office
contact person: hone#; ❑Health Department
aa e ,ed Sept.ywp P []Other
j
1
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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 in 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 locaflicensing agency shaltwlthhold-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 rearmed 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`9aw"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.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office d Inllesdoadens
600 Washington Street,7'"Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617)727-4900 ext. 406