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50 MEMORIAL DR - BUILDING INSPECTION M r r ..5'r. s s Py3� � • �S e �� `,� �� r I�uiwellifi €f>o rneny�iltp? W v x'ha c p'at y&mi r.5utY' admj�l - r syw,. � ''�N Rr� j�i;�' R" � IIWaLIktV"�iY ( z 6 z( 4 +" r /"�a�7 '• z��31 Nam'. tz J s1 F ' � aalr}Ar 9d� " ��j*•`o- ~E� �r"� �k ' f{ �rc�� �,+`, ' >r ,�i T rt •: �•z t e s �. a y— JA y £ Fph sE 'Dcx•M � w 'az��if";bt r Y� LSOx�a' s � r S+^ � ro d �yF. �i� y�44(pp�Ab �� zr �x1.-'.' yz•- �Mo'�W� 4��$ k U r'����'M� ��I�IC9R�ISQi�Wn� )© a�Q 9'z 'r"�TI n y'v Z+sr vSY `' t s e �" t"g �SaQ�r Jv4'�/ k,�"'��1Sy' ` �,�,�v'':a �ayq�'` � a� A 'A � � O�PfOjACr fi �8imlt,Fbfri Estlmeted Cott X sfi/Sid00 ReatdentGrdr * r 5�-'Tn 'yts��`° y'�`�+•��,s€u"�r „'rp v5 `' a F� .�1�,Y(�IIIA����y�. ' 9: e -. Y h l t -,2 . � 1f33 (�I�IfAare that 811 Nelda ars prapirly�nC feyitlJy written to=-avoid dAlAyll In proceaelrry y; x , x s r^�ws-'qy"i1 � k� �.fw' �fir ¢,,�b�x:,y fir• :•,. Y r ` 1 '. " a,�-"e' is �' r� r � q �irtds%�n�tl doep frerebyr9erfoh 9uildln I� udo axert tbb fdpply �7 ik s d''-� R x' C `�6�One�`^ .SIQ►iAd Ufi"dw pAna1ty 01 per�Ur k r "F -' "f' ..z x uY F ps•- > +;z•� 1a �� '-` af1 w . t t Y �sPJ.M � "ai''*�^k ms^Y"l+r` z ': .a �alA _ r •fy;-a5 " Jai _ �` r fi ,p.,�,�+*+f�Rw'' ^���� .�{�(�(yy� t'a '. K t � 'v'r't J '-,+ �e z r F h'L- `*'4a°"�y a#'"+ �•i' � Au �'x'�ri�*�-' em ,�'a�� r's .1 �. '`9"`' `yc e "^. '•a rr.Y 3r.r���si✓'r�a 9s' -r't- •F - 'x A yfd *Vy kW i2 1�� �, �.G `4 # S h }x �^ ➢ R'i� 1 5 f xl'th9°`siriz b Hr�✓, �:f $ r i ^tk � � a, .r �;.,py�„ej�fi'v' '�4 �' '�^,�3°t vv "z,a "` u w � a�. r _ '�5 ✓ ^` i a : W k;'�, ��y',k.s�� u�- � >��r >Y� . _ „j5'`w 0 y Nam, t y rwYr '4- wr +"jz r, ems• 'L lr .. r Y az t 5 1a n z ff iaF `3 y n+Ss © r an „ 2 rx r s a r x r s t P r 56 iC> r a �. vw S eM"� xf s$,�,1� ra j�z sa,�I { s 4`x'ril G r c r v y r 4 s _1 .r d y! a err 5��s3kRij y;•+ "t his W F`r; -fi'"5^asyO3av xn- C ..e�? _ ''fie r r s.. 7 �,!, y✓.r 2 OWtd. =;ip.T r 3 L The Cbmmonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 11/1. Address: /pio1/lwoa �/ L�— City/State/Zip: lele_;11 . 4; f- Phone #: Are you an employer? Check the appropriate box: Type of project (required): I.❑ I am a employer with_1 4. El am a general contractor and I 6. ❑ 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. $ �• ❑ Remodeling ship and have no employees 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 officers have exercised their 10.❑ Electrical repairs or additions required.] of 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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' 13.[_1 Other 06F� comp. insurance required.] •Any applicant that checks box#I 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 subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /Insurance Company Name: G 9J Policy#or Self-ins. Lic. #: U O / / Expiration Date: Job Site Address: City/hate/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 certify under he pains and nal ' of p u that the information provided above is true a d correct Signature: _. Date: G Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 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 #: CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ...\I::r N I r.Y!`OWA.01 L %WoR l?C�l'.\i11IW;:JA:)IEFT�1\Ci'N,fit.\\i\( rl.h 115 ii9l: ht:97L745.05" •FAX OMAC-9846 Construction Debris Disposal affidavit (required for all demolition acxl renovation work) In accordance w ith the sixth edition of the State BuildinS Coda, 730 Cb1R section 111.5 Debris, utd the provisions of MGL c 40.S 54; Building Permit M is issued with the condition that the debris resulting ftm this work shall be disposed of in a properly licensed waste disposal facility as defined by.MGL c 111. S 130A. The debris will be transported by: le I Iru+�of luular) f lie Jabris will be disposed of in Lryl p> s s r f o MR h - � ? U s11� � F pff^M� ws x' S 15, Mmowso Its 't q t s a M1 4 i {Iva A 'rs`Y"hwp ` x 50 s ORt�A�►' �K "4 S da, i rd nt ..«- , t o'Sr4 4 3 J >T _ i O�1 • 't5r r y J trd" SStic f + a - - f - ( Eaf, ' t r r k _ lIgAwy Ar�p1K,[�l Is,fo�atsd In�.Cohservafjon Pirsi YM HlaWric Dtslrkt YM nya Own atN F MOW too I A xk 55 a xf r 3 k a 7` raa 1 t F f J IMS C s g iOH�GtT .c ' e lm�r �sn 2 jyiV L t1tt " x k r s r=xj 77`;7kaa, .+ ,r _ k!« � �P4� rt b t MA'd ifl� P i y f �t:xfstirrg ; - y „3n.� 1,11 N � a , �� � Nucnber:of StOf{es Renovated x' y v`ai.2r. q'ftp�Iy1 �1se .s` ( it- j.s a £ x �Nerll `� f spa rR x 1,4 I vlsff �r•��i* PAW 3 a t a b k Y ing i i , NeMr� r� xh se a a ri iJe m s 3 w c „� 77. 3�� fit a rh to ur k a � (�Jtv*s, `,ta3sr xsssPi� r t` . ix e b ��' grxz.�2n a f d - r„ 3x r�` � `Je,.�Zr �y 1 w s � r l /I f ✓ r tt ,[� � � �' '� 1 i s _ymmy AL v 4 sr{,r / q' .a .. .- .... wr,.r.�... .: ..a ' ry , ssmn . �. m_.. e Y .A.-...i`�;' _.m-^`t. -e:, <�,,.«• �'�