250 HIGHLAND AVE - BUILDING INSPECTION m
Rr
. Y! s* �tsHiST�E fIL{��f/fl,APPROVED D1 14L
g p Tp1 PFf1�A TD A.PEAMIT BEWG GRANTED
y ICITY OF SALEM
Date
No.
Is Property Located in // Location of /
the Historic District? Yes_No V Building
Is Property Located in
the Conservation Area? yak—
BUILDING No
PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidi str ct Der�c, Shed, Pool,
Repair/Replace, Other: on
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 S
Address & Phone
Architect's Name
Address & Phone l f I
Mechanics Name
Address & Phone
What Is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Asbestos?
Estimated cost '�s)City License # N " St at License#X 7
Home Improvement
Signature o hppiicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF/WORK TO BE DONE �
Ab— L`n5 i, ee/ f5
MAIL PERMIT TO: S
No.
APPLICATION FOR
PERMIT TO
LOCATION.
a
PERMIT GRANTED
3/ :7t7:0� � ►
# 4
APP Vf�D
INSPECTOR F BUILDINGS
x�
The Commotswealth ojMassaehusettJ
Department of tndustrlal Accidents
Qfflce of Inmstigisdons
ki 600 Washington Sdeet
Boston,MA 02111
wwmmascgou!dii
Workers'Compensation Insurance Affidavit: Bnflden Contractors✓Elechidans/Plumbers
A_pDtkant Information Please Print Legibly
Name
Address: /
City/State2ip: o 9 Phone# c ,p4i2
A c o an empto er?Chock tkr�oroprlrte loos. Type Of project(rcgdred):
1. I am a employs wiih f 121 am a general contractor and I 6. ❑New consaoction
employees 0A and/or part time).• have hued the s U coultua rs
2.❑ I am a sole proprietor or partner- listed on the attached sheet S 7. ❑ Remodeling
ship and have no employees These sub-oontractota have S. ❑ Demolition
working for me in any capacity, p'o �ii'cqmp•,t :. cit 9• ❑ 8 addition(No workers'camp,insurance 5. ❑ We are a corporation and its'
officers have exec F ME-] Electrical repairs or additions
rogon�j tsotl their
3.❑ I am a homeowner.doins all work right 0fezemppon'pd MGL 11.0 Plumbing repairs or additions
myself: [No wmkcW.compp c. 152,11(4X earl we have:ao 17-0 Roof
insurance regairad j t. employes [N6 wdikeri' ;
comp.assurance regpired r „ 13.❑
;Any applicmt ttut chub boa 81 need Won fig opt*noction below showing dwfe.wa ft oompq�1. yolwy mom;
t Homwwnm wbo submit tlh sffidevit ioNcNnq dwy m doing all work and than Mie`ou' eenkeoto M wtrnit s new drdavit indicating ouch
tConVacWs Md check this box'MM ateched a additional sheet ebowioa the nvpe iifttiamb coaftoloo meltab woeken'cony poh y mfornmeon.
flitan ap employer chat ir prapldbda worken'eomptnsedox lasuraree for ary e"00sln: Below is the poltty and fob shte
Insmanc a company Neme:�
Policy#or Self-ins.Lia #: _ 'Expiration Date:
Job Site Address: City/State2ip:
Attach a copy of the workers'compensation policy declaration page(showingthe number and hull
Polley on date
Failure to secure coverage as req*W under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisomnem,as well as civil penalties in the form of a STOP WORK ORDER and a Sue
of up to$250.00 a day against lbaviolatot Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
nnnnnnw
1 As hereby cow, rthrRd7 Mfpenalties ofpwj uy that the Lrfwmd&x provided above is ties and correct
Phone#: y' ✓/I J u zo-61A
o leld des oily. Do eat write to Ms art,to k compked by e y or AWN offleial
City or Town: PermWUcense#
Issuing Authority(drde one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
o.Other
Contact Person: Phone#-
Information and Instructions
an doyen 6o pmvi#wWk9W compensation for their emPlayeeL
ter 152 requires emP ct of
ws contract Lae,
Massachusetts General La � in the service of another under any con
pursuant to this statute, an employee is defined as"...evayperson
express or implied,oral or written
An emplayss d defined as an individual.partnership,association,corporation n or 9fa deceased employer,legal entity,or any two or tame
and inchidiuB the legal represortatty b m tLa
of the foregoing engaged m a Joint enterprs9e, association
or other legal ortity,employing employeeL Howcva the
receiver or trustee of an indivfdual,partnership+ spartmena and who resides therein,or the occupant of'tht '`
owner of a dwelling bouse having not more rhea three
dwelling house of another wbo employs persons<n do maintenance'construction or repair worlr on such dwelling house
or on the grounds or building
appurtenant diweb shall not because of such employment be deemed to be an emP10M."
MGL ebapter 152,125C(6)also stasis that"every state or local licensing agency slang withhold the Issuance or
W a business or to construct buildings in the eommonweaMi for any
renewal of a licenae or permit operate of compliance wMY the laser wee coverage required
applicant who has not produced acceptable
evidence Additionally,MGL chapter 152,125CM state"Neither the wmmonweatlb nor any of its political subdivisions ahaII the \
onnect for the performance of public wont until acceptable evidence of compliance with insurance
enter into any c
requirements of this chapter bave been presorted to the contracting authority
Applicants
lion affidavit completely,by chedring the boxes that apply to your situation and,if
Please 5q out the workers'compass with their certificates)of
Please lij apply mh contractor(s)name(s),addmews(es)and Phone numbers)along with no employees other than the
insurance. Limited Liabft Companies iI I G9 or Limited Liability Partnerships(I.L p)
hers or partners,an not requited to carry.workers'compensation insurance. If an LLC'or LLP does have
employces,a policy is required Be advised that this affidavit may be submitted to the Departmort of Industrial
Accidents for confirmation of insurance coveragt: Also be sure to sign and date the affldAVIL Ilm the affidavit
tnenthof d
be returned to the city or town that the application for the permit w or if you an rogaired to obtain a workers'
l�trisl Accident«, Should you bave any questions rewnbawft below. Self-mstucd companies panes should enter their
leas¢call the Department at the number tlsied
compensation policy:D,.. on the tie Tina
self-instuance license.
City or Tows Official
please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ce of Investigations has to contact You regarding die applicant
of the affidavit for You to fill out in the e Whichmter w� as a reference number addition,an applicant
Please be sun to h11 in the petmidlicens lications in any fen year,need only submit one affidavit indicating current
that must submit makVie pami �Job Site Address"the applicant should write"all l=dM in (city or
policy information he necessary)., or marked by the city or town way be provided to the
town}"A copy of the affidavit that has boor officially stamped
applicant as proof that a valid affidavit is on fr7e for thmre pemrita or licorses A new affidavit most be SIIed out each
ear.Where a home owner or cithm is obtaining a license or permit not related to any business or commercial veatsre .
(i.a a dog lice=or pemrit to bum leaves etc.)said person is NOT required to complete this affidavit
ThaOffiM of tavestigations would lilts 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,telepbone and fact ormber:
The Commonwealth of Massachusetts
DgWtmeffi of lndtlstrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 www.mws.gov/dia
CITY OF SALEM, MASSACNUSETTS
• • PUBLIC PROPERTY DEPARTMENT
K 120 WASMINGTON STREET, 3RO FLOOR
SALEM, MASSACNUSETTS 01970
STA14LICY J. USOVIC=, jot. TELEPHONE: 978-745-9599 EXT. 38o
MAYOR FAX: 978-740-9848
Salem Building Department
Debris DkDosaal 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
Chapter III, S 150 A. lm as defined by MGL
The debris will be disposed of in:
location of Facility)
Signature of Applicant
Date