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6 NICHOLS ST - BUILDING INSPECTION fLWN6.MWT-0E f,Kmw#ND APPROVED BY T44E ,fplSi ZC=PWR TDA P.ERAfff BEING GRANTED CITY OF_SALEM No. d� \ ow la 3(oS "mmoft Obelq?� Yam No Budding �f G �iG�1d�s Is Properly Located in me Cawrvalion Ana? Ys_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) oot Install Siding, Construct Deck, Shed, Pool, Repair/Replace. Other: PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS N PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specitications: Owners Name of �r✓��15��;h Address & Phone 6 fi r GI,Gf s s~L LR7t ) Architect's Name Address & Phone j 1 Mechanics Name n y tr LeJA. (aec v Q Address& Phone ( 1 C What ns the purposeofbWidkp? Fr'i' G7(S}f�n5 �0r Matwfat of btrld V? a a dwW*,for how many fwnW? 3 Will hAdW q cordorm to law? Asbestos? eaflrrr.td coat 90t000 , cW Uosrw• N A sl cenaeue U a CS ofl37a � f.�6 -� X Pq- Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE br v MAIL PERMIT TO: 9 ✓l i a had NO. APPLICATION FOR PERMIT TO LOCATION / PERMIT GRANTED ' 2.0 7WOVfD INSPECTOR OF BUILDINGS i� 1 d , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electlicians/Plumbers Please Print Legiblv Alpiplicant Information Name (sasinese/OrBaaizati on/Iodividuai)• 57cj �1r /7 ,1Mxa1 Address: 7 rQ 4vc City/State(Zip: Qahu� M d//)) Phone#: 2F Are you an employer?Check thr proprlate box: 7sbeeL T ype (required): I. `MI am a employer with� 4. ❑ I am a generald I struction 7. employees(11A and/or part- have hired thetorsing listed on the a t 2.❑ I am a sole proprietor or partner- These sub-con onship and have no employes workers' com - addition working for me in any capacity. [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their afrs or additionv 3.El am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing rep myself. (No workers' comp. e. ploy employees. ( and or have no 12.Q Roof repairs insurance required•]f comp.insurance anc workers' 13.❑ Other comp.insurance required.] . ;Any applieent that checks box pl mu o fill st d out the eection below showing their wolkw eongmntion policy mfomxtiow t Homeownm who mlxtrit this afGdevh indieatmg they ate doing ell work sad than hire outside contactors must submit a new affidavit iodiceting such tCootmctms that check this box must attached an edditiossl sheet showing the name of the sub�contmctom and their wotkea'tong•policy isfomtatioo. 1 ant an employer that is providing workers'compensation insurance for my employees Below is the poUey and Job site information. Insurance Company Name: /J/a� Policy#or Self-ins.Lic.#: �f S )7 Expiration Date: C �/rc�s/f S7 Si, A- city/StateiZip: 0096 790 Job Site Address: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 onayear 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 msu rsllw coverage verification. 1 hereby do certify the pains and pe of pedu-7 that the information provided above is true and correct ��� .-7r Date: rJd�/�r S' P hone oadje Do not write in this area,to be compkted by eity or town 00CUL n: Pernlivueense# hority(circle one): Health 2.Building Departmect. 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1111Va alafaa&%FAA Nll%i 111►7&A aa\.a,A%#XA7 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 Lire, 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 trustee of an mi ividnA 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 15Z§25C(6)also slates 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 commonweakh 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 enta 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 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(sl address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies 01.0 or Limited Liability Partnerships(I.I.P)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 affldaviG 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 nnmba on the appropriate line. City or Tows 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 pemmidifcense number which will be used as a reference number. In addition, an applicant that must submit multiple permitticense applications in any given year,need only submit one affidavit indicating current policy infomtation(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 borne owner or citizen is obtaining a license or permit not related to any business or commercial venture (ie. a dog license or permit to burn 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 mamba: The Commonwealth of Massachusetts Department of Industrial Accidents OtBtx 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 The Commonwealth of Massachusetts t Department of Industrial Accidents Q©5ee of Invesdgadons. 600 Washington Street Boston,MA 02111 www.massgov/dlle Workers' Compensation Insurance Affidavit: Builders/Contractors/El ct idase Print umber Leffiblv Applicant Information Name (Basiiresabr>pv tiOa1� ): Y'1 Bryn ✓ Gd°1r7`r✓fhOh Aihtxs• 5-7 R . (r/r/YG Sf. City/Statet p: Sk(cwt Phone# G6Z—�l7— Zt�f� r- 3 7eqmp�-7 mployer?Check the approprlat Type of project(required). mployer wick 4. am a general contractor and I 6. ❑New constructionea(fall and/or part-time)•• (((( bout hfred tLe sub contractor � Remodelinglisted on the attached sheet tole proprietor or partner- I hose sub contractor have 8. ❑ Demolition have ro employees workers' comp. insurance 9, Bur1dmg addition for the in any capacity. rkers' comp.insuuance 5• We are a corporatron add its ]0.0 Electrical repair or additions .) officers have exercised their 11.❑ Plumbing repair or additions omeowner doing all workright of exemption per MGL[No workers' comp• c. 1sz,§1(4),and we have no 12.�(Roof repairs ce regttirad)t employees. (No worker' 13.[3 Odler comp.insurance required.). Any epplieanl lhet checks box#I must also fill out the section below showing then workers'corrryensesion policy information.' Y Homeowners who submit this dit&vlt indieatieg they we acing an work and iben hire outside contractors must subruit at new eBidevit indicating such ®additional skeet showing the name of the subconbactors workers' end their comp.policy information. :Contrac0ore 16st check this box mu#attacked I am an employer that is providing*Vrke►s I compensation insurance for my employees Below Is the policy and fob sets informattom ��p R 6'dl k Del Insurance Company Names Policy#or Self-ins.Lie.#: Ro qo 360p -1 Expiration Date: Job Site Address: 6 City/Stau:Mp: 94+1 i'"' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fsl'lure 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 imprisomnent 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 eerdfy um�ar tkt Poles and Pemakies olpwlu►y:hat the imfamation provided above is tnu and correct SiMa=: QLct �� Date: IUl3/�oS Phone# l7 V Z— 771t3 rCkyorTown e only: Do nor write in this area,to be comp/elid by cby a town oo7chd : Per illiucensethority(circle one):f Heakh 2.Building Department 3.Ckyrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector . Contact Person: Phone#: 1ll>Va ARA"WiVll "&A%& i11061 alq.biVil►7 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for then 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 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 pint 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 throe aparttnents and who resides therem,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 contract buildings in the commonivesiM for any applicant who has not produced acceptable evidence of compliance with the inaaranee coverage required." Additionally,MGL chapter 15Z §25C(7)states"Neither the commonwealth nor any of its political subdivisions Shan 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 fin out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contactor(s)name(sl 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 Depart 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 fni out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitlicense number which will be used as a reference number. In addition,an applicant that most submit multiple permittlicense 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 the or town be provided to the . . by �Y may Provr 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 (ie. a dog license or permit to bum 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 5-2f�o5 www mass.gov/dia �• rni nN AI4 OTS-31B-8803 T-841 P.000/024 F-S37 fl, .. F� :'I,wr P I�x1r ����1� ��+F`�iVIe'�1�:v4•• I ...'il�'+,�• �• .� .^!'.'� fu Y ' y'r PR DUCER THIS CERTIFICATE IS ISSUED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE eby&Wyman lnsuranoe Agency Inc HOLDER THcatIS CERTIFICATE DOES NOT AMEND,EXTEND OR rry, 26 ly. A o19 ALTER THE COVERApE AFFARDED BY THE POLICIES BE T MA 1915 LOW COMPANY A GRANmE STAATEF NSUIRANCE COM ANY IN UREA So M Girard 7E Jen Olen Avenue Da vers,MA 01923 THI IS TO CERTIFY THAT THE POLICIES C VE17A10E$+' in'.E.' .";a: x .':..,.• r• OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR` TH POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DO UMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE PO ICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN HAVE BEEN REDUCED By PAID CLAIMS. LTR OP CC POLICY MBER POLI Ta Pa 8%PIRA OATH A DEA@LOYfiRFLIAMLnY j NE PROPRIETORI LIMITS ARTNER31E%ECUTWI! PFIOERS ARH: INCLO EXCLD 2786553 8/03/2006 8/03/2006 TN TUTORy .Mae At+P4ea to MA Opemoono Only. ,W, ,. n 'MOW $ 10D,0U POLIOY Ismr $ 500,000I ESC OF RATI �q1 100000 RTIFiCATE HOLDER CANCELLATION W N OF BEVERLY W70Q•D nNroP TNc"°rn'e°EHo"reen rcurres ee cArceuED Hs>:oAC T� 1 ICABOT STREET S7iP RATU)N DAT6TNEIWOP,THE 195UM6 CONPANYWi64 SNOEAVOR TO AUa.1Q VERLY, MA 01$15 DAYS WRIT M N"MTO'HE CMnFIb1TI NOLDEN NA"O TO TH@ LEFT.BUT FAILURE TO MAIL SWN NOTICE 91441.IMPOSE NO OBLIGATION OR UABILITYOF ANYIDNDUPCIJTHEDOMPANY.IT6AO0TB6r4wp ewATIz& `•! AUTHORIZED REPRESENTATIVE ;a � k ✓/tC 70om/GC09u/M.2L[IL _�✓/ /E[lde�s f t Board of Bmld�og Regvlahove aad Stavdsrds �r +w &„ ., License or registration valid for iudmdul asdonly` ` HOME IMPROVEMENT CONTRACTOR'' '�� �� - before the exp�rallogdate ff foqud return to; 5 t 1 4Board oiBuddmgRegulah9ns,and Staudbrd� Registratio�`,:t35190 �, Ove Ashburton m Place R 1301; ' Eapir'atfon2012006 �A c£ � Boston,Ma 02108 s li-GIRARDCONS i 7EDENGLEtf'AVEy� � � � lYpp °' DgNVERS MA01.923 . . ,..Advumstratort ,tkY z , ,si .,Not valid wrthoutsiguature � q i • o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 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: �r,rf5c%dr, «r�-'nf (Location of Facility) lA'! uM Signature of Applicant 114131105 Date