22 LYNDE ST - BUILDING INSPECTION -PL-*"s1dWT13Ef4L+9-AND APPROVE0 BY T44E
.LNSPFCTDB,PWR TP A_PEHNIIT BEING GRANTED
CITY OF SALEM
Date
to oS'
Is Property Located in Location of /1
the Historic District? Yes No /" Building z
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: lt&AU- l4Tcr cW CA&mm/Re-ArtC6
Fu0.n1A( E l/NSOgtL hJ eW W/NC>ZUZ
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to ild according to the following
specifications: � 1� �( ieF --
Owner's Name 1 N At Rev � Tg7 t-�
Address & Phone
Architect's Name /JZ
Address & Phone
Mechanics Name
Address & Phone
Whet is the purpose of building? /
Material of building? FLU ,-Z E5f lctl, If a dwelling,for how many families? tO
WIII building conform to law? Asbestos? TD
Estimated cost" Dom_City cense x N ' state Ucemse ' 5
Bc.e Laptuveaeat
"l�—yL�J• Lic. i
Signatu p icant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
A� I
MAIL PERMIT TO: I41 PVMWIAPO ��'—
No.
APPLICATION FOR
PERMIT TO
LOCATION-°
PERMIT GRANTED
APPROV D
rVtCTOR OF B14iLDINGS
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
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 III, S150A.
The a ns ' be di osed of at: 1_� �L
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�D .
Name of Permit Applicant
Firm Name,if any
Address, City & Stkk
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.
The Commonwealth of Massachusetts
7 Department of Industrial Accidents
Ownstiosesujwoas
600 Washington Street, 7 h Floor
Boston,Mass. 02111
aA
Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
address, 114N
city t`f��V-�- state M ZiAlI n�..t phone#
work site location(full address): �a7l—
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[Wemodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
-- ---- -9-4amaraempleyer-providmgworkets-eompensauon-for myemployeesworkingonthisjob
f4 m,,�:. sr E .� +y-',b,•
Comnanv us i as
xx
address ,
1 y� i�.. sM1'kM
city: �[��///VVV•••��_ t ��.G., a, „krr a�<_r rr '' rr� 'i`rtt //
7,
inG r r�tfS Oa7 tFl.lt�
❑ [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,• ,
address:
a
4 v
•;y.z.y r . ; tl :.:< f ;,'.a 51, F4.nz; `h'P^f Pk's $i,,,t•k x •"'# .w k +.rx+xsP
company Rome;'v
r r
address,
I'M
wA«.:.w.«.�:..�",.w°.L'^+'...«,'uw.,.+.w..."�v"'^"2'"'ixii`."' ^yx.. .{ r'•4? ("'p„y '".
in 4 s , ro , iff
Failure to secure c ge as required under lion 3SA of MGL Ill can Ind to the imposition of criminal pensifirs of a fine up to S1,300.00 and/or
one yeah'imprlsop"meot ell as civil penal ies In the form ofa STOP WORK ORDER and a fine ofS100.00 a day against me. I understand that a
copy of this statement may be rwarded to a Office of Investigations of the DIA for coverage verification.
1 do hereby certify under/ nd penalties of perjury that the information provided above is true and prrecf.
Signature Date
Print nam Phone# G ! h 9 i 24#Ll
omcial use only do not write in this area to be completed by city or town omcial
city or town: permit/license a []Building Department
[]Licensing Board
❑check if immediate response is required ❑selectmen's omce
contact person: hone a; ❑Nwlth Department
vnna sePi.S�xnt P ❑Other
Information and Instructions
Tres all employers to rovide workers' compensation for their
section 25 requires P
Massachusetts General Laws chapter 152 se eqP
Massa P
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
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 1Oca-licensing agency shslYwithhot&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 not 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
- - n .<
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
010ce d IniMlladeee
600 Washington Street,7'"Floor
1,7 Boston,Ma. 02111
fax'#: (617)7274749
phone#: (617)727-4900 ext. 406