152 LORING AVE - BUILDING INSPECTION IMOSi'-91E ffL{-� APPROVEO BY T44E
UNSPjCT 3 PWR T-O.A.PERMT BFMG GRANTED
CITY OF SALEM /
RJ N�o -- � ) �x ,, Date
( s��
�`wM1N6�J
Is Property Located In Location of q ,/
the Historic District? Yes I1_No Building 1SZ V E'
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Retool, Install Siding, Cgn truct Deck, S Pool,
Repair/Replace, Other: ?(IL�KfhR V(d(llSDvr(S � Tn
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-
r
Owner's Name
Address & Phone
4 Architect's Name
Address & Phone
Mechanics Name
Address & Phone � "( 4R j 100 ) 20 p21L.
What is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos? G
Esumated cost $oar ilk City License ae
Home Improvement
Lic. 06 S' n to a of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION� OF�WORK
p TO BE DONE
/1
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PUldiLt 76 A C4 dCk0
MAILPERMITTO: SSE PA5WE 3� Q ,JST- fJ9tL l M'+` 62( '(�
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APR OV�D
�t g
0SPECTOR OF B LDINGS
r The Commonwealth of Massachusetts
%- Department of Industrial Accidents
Office eflnuesugatieas
600 Washington Street, 7r"Floor
Boston,Mass. 01111
�s Workers'Compensation Insurance Affidavit: BuildiinPlumbin Electrical Contractors
'A li�'�'c ntmform tio(n:raAbly, �,kz:v: - _ .:-v..v: s.�.,....�..
Am
name: �,/ }���W-a x I r6U,16 64 ��.
address: .fib l7e 6d - I- /� p
city / state: MA zip.0-M phone# 60'- OUL
work site location(full address) W t—Ifz ]l yf -
❑ I am a solemeo 3�er performing
and have
all
one working i Project Type: ❑New Construction❑Remodel
am a homeowner erfortnin all work myself
n any capacity. ❑ Building Addition ' 'L'k(1G([�� Vigo 4V4,fsL14I am an employerr pAr�ovidinngworkers'compensation foor my employees working on thisjob
company name: i V'1rl C74uV7Alft-- ( N� Il��
address:
city: t/v lA.t� 1 - � - �"' phone R• Ia�� �l Out� + 4 ? ��
�drlJr S'i4Trc vs, CA, a r.
insurance co.
❑ 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: -
cotonanv name•.
address: . ..
city: phone#•
insuranceco. MOUSY#
company name:
, 3
address:
4 a
city:. ..�, ,.... .• :x . ..- ,,:. . .,'•.ohoneN• .•,. ,4ry-. ��... ,� a� rss��." �,� `
insurance co. lic # = .- ..*...: .„
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 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy orthis statement may be forwarded 10 the Office of Investigations of the DIA for coverage verification.
I do hereby certif I (err ieapains and penalties of perjury that the information provided above is true and -orrect.
Signature Date / Q
Print time Phone# ( Zl o�L
official use only do not write in this area to be completed by city or town official
city or town: permitflicense q ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Once
❑Health Department
contact person: phone u; ❑Other
Im "e d Sepl.2a1)31
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 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
P maintenance construction or repair work on such dwelling another who employs persons to do p g 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 local licensing agency shall withhold 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 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.
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
otflce of Inuesugadons
600 Washington Street,7" Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
ti
Mass.
, Dated�1"_�/ 19 Permit# w
Building Location jr•Z L�K.yJ1�L� jVE r Owner's Name /OIL r ,�9V17 7 �•
.S4M( /'/f✓ Type of Occupancy_ .Z r�iD►iti�
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ NAE3'
FIXTURES
Z
Z N
y Z Y
h N .N O Z h. } N
W Z J N g . fQ„' N (7 Q C
N Z N Q ¢ ¢ _' N y
N N N S ¢ W N Y ¢ 6 a ; x
¢ W O 7 ¢ a N ¢ Q W N O Ic J = ¢ 6 ¢ W
W O O
U. zi I
h V j h O S 6 N h Y 3 O ~ 2 S Q W 4 Y W
_ Z O O 0 W �' O 0 S
3 Y J m N N Q 'Q O Q J J Q ¢ ¢ ¢ Q O Q h
N O O J 3 S h N W V 7 0 Q 3 C m O
SUa--es MT.
BASEMENT
1ST FLOOR
2NO FLOOR
3RD FLOOR
4TH FLOOR
STHFLOOR
STHFL00R
7THFLOOR
STHFLOOR FF
Installing Company Name j��fSS Check one: Certificate
Address L AAW ❑ Corporation
fj ❑ Partnership
Business Telephone 00 -6340 Firm/Co.
Name of Licensed Plumber r
INSURANCE COVERAGE:
I have a curr nt lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesdx. No ❑
If you have checked Yes. please indicate the type coverage by checking the appropriate bSgt.
A liability Insurance policy 44— Other type of Indemnity ❑ Bondi
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent❑
I hereby certify that all of the details and Information4nn
tted(or tared)in above application are true and accurate to the best of my
knowledge and that all plumbing work and installatiunder permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum Ch 142 of the General Laws.
BY
Title Signaldre of UcensedPlumber
Type of Ucense:Master❑ Journeymar&
c3tAP /Town
License Number
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INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked yes. please indicate the type coverage by checking the appropriate box
A liability Insurance policy ❑ Other type of indemnity❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
Signature of Owner or Owners Agent Owner❑ Agent 0
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOK
Registration:.. 130306
Explra-tion2 yt6/2006
.y
Type:_Individual i
STEPHEN PASCOE
STEPHEN PASCOE -
114 HANCOCK ST. _
EVERETT,MA 02149
Admfnl��_
y�. lG�.r "..
BOARD OF WIU*ko llEtilMT
ueense: CONiMtknON t
a�sr�W t7\31. 1
did
L h�'
... cted To•
STEVE PASCOt=` 77
A
PO BOX 937:r.t
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