67 LORING AVE - BUILDING INSPECTION �I�IIl16iM M;r-eEfIL{-q_*W APPROVED BY T44E
JUSPFCIW PWR TD.A.PEW REMO GRANTED
/ CITY OF_SALEM
No.37L" Data L a✓
�i
Is Property Locatedthe Hkgodc District?In Yes_No >lulldiag Location Offd �O
Is Property Located in
to Cormatvetlgn Anna? Yes NO
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct De4, Shed, Pool,
Wi
Repair/Replace. Other: t,l! Ise i E-N I Si �
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:
i
Owners Name
Andress & Phone kSwr��+Dr� "V _APW_ M4
Architect's Name _
.Address & Phone ' 1 i
Mechanics Name �f W0&RR6N CA
Address & Phone 1/Al r7A, A� L��) g 2 7 0S
/ l i & t �J 1hq 0&/-t'—
whet Is the purpose of building? cl (n�i h Z7C—
Material of buiding? G)?S^W If a dwelling,for how many famitles? /
WIN building contort to law? F ° Asbestos? /e b
B
Estled cost �/D e City License r N P' Uowtse r 0 5
rtw r 2
Ham Improvement
ent
JS ', nature of Applicant
ED UNDER THE PENALTY
OF PERJURY
J� DESPRION OF WORK TO BE D l
rs tT �fL, ILL E6I a
MAIL PERMIT TO: Cd "
M4 U ! �/
l
No. -;�C ✓
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2.0
a
APP O �D
INSPECTOR F BUILDINGS _
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CITY OF ,ALEM�= A5574CHU_SE
PUBLCC PROPERTYDE AMf#T: Y
_ 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
�mnra 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 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 S150A.
The debris will be disposed of at:
Location of Pacility
gna a of P 't Applicant Date
FULLY complete the following information:
(PLEASE PRINT' /CLEARLY)
c Andes
Name o ermit Applicant/
Firm Name,if any {�
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
�\ Department of Industrial Accidents
Ogee of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aipplicant Information Please Print Let=_ibly
Name (ausuressrorprization/1Miviaual):
Address: ?n w� 0 V E q
City/State/Zip: Phone M / �� 9� 06 z7 /
Are you an employer?Check a appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).s have hired the sub-contractors 7. ❑ Remodeling
2.( 1 am a sole proprietor or partner- listed on the attached sheet =
ship and have no er„ployces These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 11.❑ Plumbing repairs or additions
3.❑ I a homeowner doing all work c 2,§1(4 d),an a have no 12. Roof repairs
myself. (No workers comp. ❑ �as
insurance required]t employees. (No workers' 13.0 Other
comp. insurance required.]
•Any applicant that cheeks box#1 must also fill out the section below showing ther i workers'compensation policy infom ration'
t Homeownens who submit this affidavit indicating they are doing all work and then hire outside cantiactors must submit a new affidevit indicating such.
tContrecton:that check this box must attached an additional sheet showing the name of the subcontractors and their workers'corM.policy information
I am an employer that is providing workers'compensation insurance for my employees. Below is the palky and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie. #: 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
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
of 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.
I do hereby eertify under the pains and a allies of perjury that the information provided above it true and correct
S' ature: \�Lp�i11 Date: I L C)
Phone#: �� -Yl-
Ofjleld use only. Do not write in this area,to be completed by cky or town ojjlcial
City or Town: Permlt(Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
lniormation anu jn3tiL ua twi<ia
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employs 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 a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or.trvstce 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,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to constrict buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 15Z §25C(7)states"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 incuratim
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 permi0icense number which will be used as a reference number. In addition,an applicant
that roust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like 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,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www,mass.gov/dia
Henderson Construction
28 A Winthrop Avenue
Beverly, MA 01915
(978) 927-0544
�J •
(Date)
In accordance with section 110.5 of the Massachusetts State Building
Code, the Owner(s) of:
n
ko-
Ole
hereby authorize ' enderson Construction, to act as their agent, to apply
for a permit to accomplish the work as described on building permit
application.
(Signature of Owner)
R A �R I Aa 66,_s
(Printed ame)
(Address)
y'V