2 NAPLES RD - BUILDING INSPECTION f{�g�Y�EfW�Mip �PPFIOYED 8Y ZIiE
JdSP�rsos POIOR ZDApfJNf AEINt3 GRANTED
a CITY OF_SALEM
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RUALDM PERMIT APPLICATION PDR: .
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gher:
PLEASE I "WT LEWKJ&COMPLETELY TO AVOID DELAYS W PROCESSMrG
TO THE INSPECTOR OF BUILDINGS:
The un bmgrwd hereby applies for a permit to bWW aocor" to the following
specilicabom-
Owner's Name /COL/_o&ey R� E 6 V, �- L
Address & Phone `t FR ce K oVAj f 9 - &96 9 0 2 Z r fF�l
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Address & Phone ( 1
Madlanim Name //o L COVG r4 n/ I N 5 U L �4 T!o N L L— Lei ,
Address & Phone
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mood m~ Wno D 1=(zptaq E r.a3rr.rrq,for taw sw►y trrnllw? 3_
err t eft=dwm to law? 5 ABbs"? —
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rJs. t X n of Applicant
P 7 2 Co UNDO THE PENALTY
DESCRIPTION OF WORK TO W DONE
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MAIL PERMIT TO: //o & L b eL,*N ID E L/ L L
No.
APPLICATION FOR
PEMI TO
3 Flo, 69
LOCATION
PERMIT GRANTED
2.0
Att
INSP OF INAEM os
I
CITY OF SALEM, MASSACHUSETTS
_ PUBLIC PROPERTY DEPARTMENT
o
120 WASHINGTON STREET, 3RD FLOOR
�6pMM6� SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
5 G Pe,' C ['` "%ocation of Facility) i�'
Signature of Applicant6�
DFr�Cca,a.�w ACC Q2v
L�C„
�Dt/ C `( 200'5-
Date
The Commonwealth ofMemenuserrs
Department of Industrid Accidents
of`lac of inws*adons
600 Washington St►ed
Boston,MA 02111
wwrdmassgot✓dia
Workers' Compensation Insurance Affidavit: Bugders/Contractors/ElecMcians/Plambers
Please Print Lenibly
A H n Informatio
Name
Address: ` i
city/StatelZip: ,mil P- wW Phone#: `�? � PO 2
FenVoye"
youemployer?Check thr gpptrop�rl
'type of project(required):
yer wick m a �contractor and I 6• New construction
( tuand/orpuc limhave hired the sub conuacoon _,,,,�pA ardor or Farmer- Head on the attached stave8 0De"o�ve no employees Thesesir compratsots havewortlgr me in any rop�Y• wortas' comp.insurance. 9. ❑ Building addition
5. 0
o workers' comp.insurance We are a corporation and its 10.0 Elecuical repairs or additions
rcquved.1 Officers have exercised their airs or additions
3.0 I am a homeowner doing an work
right off exemption per MGL 11.❑ Plumbing rep
o workers' comp: _" c: 152,41(4),and we have no 12.0 Roof repairs
'
employees. [No
]
insurance required.]r cpinmrance required . 13.0 Other
'may a owun VW
c*nu hex el melt ale fill out the when belowan week mod then bare outs Wft8dM mart wLamt a new afdavit inmeatiag Sisk
tliomeownwawhoethmttLfaafidavitindke4mgthey domg
tCont ud,m ded check thus box mat arw1ed so additional Sheet abowmg the Wane of Poe wAConuacton and 16ek wattsn'oomp.poltry mfotmet+on.
,an as employe that b provid/nd workers'eoxWxsadon lesuraucefor my employes Bdow is tke poll,P audjob sue
/nfon"Al .
Insurance CompmyName:
Policy#or Self ins.Lic. d: Expiration Date:
Job Site Address: y/StaWZip:
Attach a copy of the worker' compensation policy declaration page(showing the policy number and expiration date).
Failure>D secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up o$1,500.00 and/of otwyesr imprison ae well as civil penalties in the form of a STOP WORK ORDER and a lino
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 vetificatitm
I L hereby certijjr thepal"s and pe that the infamadex provided above Is trt�Md
D
F1Hj
e mbt Do ad wr&e av Wo area,to be eompkied by eity or low oaieial
own: Permitlueense N
uthoR
one):
d ilding Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6 Other
Contact Person: Phone#:
1111Va 111Na•iVaa fill{,a ili0 a.l M�.61V i1►7
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or wrltica." w
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or tmre
of the foregoing engaged in a joint enterprim and inch-dim the legal representatives of a deceased employer,or the
receiver err trustee of as individwl,Partnership,association or otkr legal entity,avbymg empbyees. However the
owner of a dwelling house having not more than three apatmtents and who resides therm,or the occapairt of the
dwelling house of another who employs pawns to do maintenance,construction or repair work on such dwelling bonne
or on the grounds or but'lding appurtenant thereto shall not because of such employment be deemed to be an wiployer."
MGL chapter 152,425C(6)also states that"every state or local Ileendag agency shad withhold the Inaaaee or
renewal of a license or permlt to operate a business or to eosatnet buildings In the commonwealth for any
app ivat.who ins not produced acceptable evidence of comptlante with the insurance coverage required."
Additionally,MGL chapter 152,125C(7)states"Neither the commonweabb nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of M chapter have been presented to the contracting authority."
Applicants
Please fill otrt the workers'compensation affidavit completely,by checking the boxes that apply to your situation sod,if
necessary,supply scab co acsor(s)name(sj address(ea)and phone number(s)gong with their ceni6cate(s)of
iusura Limited Llabft Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation jusmauoe. If an LLC or UP don have
employees,a policy is required. Be advised that Ibis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sore to alga and date the aMdavL 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
Industial Accidents. Should you have any questions regarding the law or if you we required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self maned companies should enter their
self-instrance Horne number on theappi fift line.
City or Tows Officials
Please be sure that the affidavit is complete and printed lepbly. 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 sum to frill in the pamittliceme number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtidliceuse applications in any given year,need only submit out affidavit indicating current
policy information(if necessary)and trader"Job Site Address"the applicant should write"all locations in (city or
town}"A copy of the affidavit that has been officially stamped or.ma fed by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for Mare permits or ficeosn. A new affidavit must be filled out each
yea.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ins a dog license or permit to burn leaves etc.)said person,is NOT required to complete this'affidn t
The Office of Investigations would Me In thank you in advance for your cooperation and should you have any questions,.
please do not hesitati to give us a can. ,
The Department's address,telephone aad fat ammber
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 4o6 or 1-g77-MASSAFE
Fax#617-727-7749
Revised 5-zt�05 www.mass.gov/dia