27 LINDEN ST - BUILDING INSPECTION jqA" tillSMfAj*&4 ID APPROVED BY TW
JdS0F.O7Q,A PWR TO PEWIT BEING GRANTED
CITY OF_SALEM
s
5` 1
Is Pap"Loomed in Vol" location, of
beis P"New Loomed in LYr�oiie laittdot/ Yc�_Wo._�� Il�n,7lLiloi^� a Cmwi�pp Away YM�No v � / L i n Qe h S+
BALDING PERMIT APPUICATION FOR:
Parmd t0:
(Ckok whidwvw apply) nd" Siding. Conat W Dads, Shad. Pool,
dw
PLEASE FIUL OUT LEGIBLY i Y TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
'rho undaraQnad hweby appllaa for a pem k to build according a the folbww►g
spec"gaw-
OatWa Name C k2�tj SGr I s la vt
Addreaa a Phone fQ-731 -7 y K '-7 R
Ara►kW& NW9
Addraaa a Phone c I
MadLanica Nama - 4-D
Addreaa A Phorw b4 5 C r Ln w oo c S+- l 4-;kl S&I- 57
ofCQ�j}-a'r
YAW is on pupotc d OUYdhp?
M"ol a trridrlp?U Inv[ 1 r a gyp,for now amy Walbw9
vm(um%codoen a wo
W I�ci0vo5
Er11ww0 cost g� �qq L,iatw• N A a1W LJouw•
sows lartc rn,t
Lu. f t�a&Qta
Sfgnabme of ApWAMt
SIGNED UNDER THE PE14ALTV
DESCRIPTION OF WORK TO BE DONE OF PERruRY
MALPs*AT'T ���
"I Co burn g. , -T loos ono, y o{ o l 8-7,l
Y
AP AXON FORPEFWrTO
LOCATION
PERMIT GRANTED
ds
APPROVED
INSPECTOR OF SAALIXMGS
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Bumessiorganizationandividual)::
Address: ?7I/S l 1-7 12g-g& Jpob S i
City/State/Zip: )( G C5 i Phone #: 4 7&- 5(,p9—57 G
Are you an employer? Check the appropriate boa: Type of project(required):
1.® I am a employer with /ri 4. ❑ I am a general oontracror and I 6. F New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-, listed on the attached sheet. t 7• ® Remodeling
ship and have no employees These sub-contractors have 8. E3 Demolition
workingfor me in an capacity. workers' comp. insurance
Y aP ri• 9. E3 Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
•Any applicant that checks box 711 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'corap,policy information.
1..an employer that is providing workers'compensation insurance for my employees. Below is the policy and,job site
information. / n
Insurance Company Name: N1-/// (A j S, e D
Policy#or Self-ins. Lia #: le (O D Cf 9 Expiration Date: 3 " 7
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
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
)f up to $250.00 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.
f do hereby certify under th ins a/nd/penalties of perjury that the information provided above is true and correct
iip-nature: Date 7 6
-hone#: Q 7S- 5&-9 7
F
y. Do not write in this area,to be completed by city or town offixial,
Permit/License#
ity(circle one):
lth 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Contact Person: Phone#•
CITY OR 9ALZU. MASSACNYlLZTT!
PtJWUC PROPKMW ORPAATMtNT
120%ummssmm mosav, sea run*
9"0 wsaeuuawn eve"
TULSPWWM 070-749-qN bR 380
trNY 870-740ag0
$ids Dlseessl Yoran
fa accordance adds die pmvidow of MOL c40 5.%a ooadid"of your
Bnitdln9 Pleat is War die debds d hom dds worlt shalt be disposed
of is a peopedY licensed solid were dispoW hwh,m domed by MM
Chaptes Ill;S 150 A.
The debris wilt be disposed of Im
3�5 Gc-een,&xo c-A
3'WuM a of Applicant
7-
Cl0 J� tip, easg� sy
i
i
t
i
T
7
I
I
J
Aor
{ Fre kal,,A 1
50�
j el in f
Ati Ole"70
� s L
it
,
-E
r,
I
I„
I v