24 NORMAN ST - BUILDING INSPECTION 1
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CITY OF SALEM
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SDI Ni PIRW APPUOAIM FOR:
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(Chb whin W*W"*) Roof. Raioof. Indian Skift CarftM DaoK Shad, Pool.
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PU MM PtL.L.OUr UEO•LY A COMPLETELY TO AVOID Dffk.AY=IN PROOMM10
TO THE INSPECTOR OF BU LDING&The '•
wdn+ iad hereby appin for a pamkk to bulld aoopdft oo Iha foMowNkp
Ownara Name cn v412L o G lf�I o t I
A*konaPhone 1qS gur-r-il\ 631
AmhbWs Name
Addnaa A Phone c 1
MfthW ca Name C— �— 1/6147� -
Aditn a Phone ( 1
moisftwv.aa- -- .1 condos
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SIOIfIfID LNf DON THE PONALTY'
OP PiRAWN
o�scRlPnoN OF wof�c TO BE DONE
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MAIL PERMIT TO: GIGIo tt 1 cans t 1_� c� — l� Fs F3�c-c-� 1
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APPLICATION FOR
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LOCATION
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PERMIT GRANTED
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CITY OF SALRA% MASSACMUswrT!
i -I& PUBLIC FROMM Ot►AaITMENT
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nw 40"Tuft raga o dw debris Am dla dnohdM rmwada%rehab or adw
ab ml m otbuMM or*won be dsposd is a p wpartp&=aad solid-waaft disposal
heft at ds&W by MM a% SISK and&buildio/parmite or 5---of ft
iadfrala do Ices"of as ad*.
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ueparrnwm M inausrrret eec►aefns
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6M Wasl,iattoa Shied
Boston,MA 02111
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Workers'Compensadon Luumnee AMWavit: Builders//Contractors/Eltdridan>VPlumbers
_A_DDlkant Information Pleaft Eft LdsvMv
Name
Ad&=: _I4S 6uraziIl
city lx Sj� ync (�1967 Phone S•
Are You as empbyet+d Chak tkaapproprisde tans Type dprojeet(required).
I. I am a aw*a with r- 4. 0 I am a Small OMUK or and I
2.❑ I�s�k Owl sod/ar part-timoo have Land So ❑New cauaRoctiom
pmpriew or potna- SUM oa the art shed stied 8 7. ❑ Remodeling
ship and have no employees Tbese sub-comracka have 8. ❑ Demoffdn
working fbr me in any capw*. workers'comp.iaa nsoce g ❑ > L addmion
[No workers'oan*fmnes un 5. 0 We are a omporadon add its
required l of$eers bon card ed their 10.0 Electrical repft or additions
3.0 1 as a homeowner doing an work rialo ofexesoptioa pa MGL 11.0 Phtmbiog repairs or additions
myalt[No wadwo' comp. a 152.i1(41 and we have no 12.0 Roof repairs
w tnsoraate ed 1♦ 1 13.0 Odxr (22POi Y1fiYl�
;Any aPp>�are chmb boa et ww dso GOca a.o senors bdm dfovtsa ftk wrckm'om�matlfor paq mbrmdmar
t Homeowasn vW mbma*k adidaca bat**say dome on work nd can lob.tundra eodonctaes uma mwma a aw afij8cva sacating melt tCortradon So check Ab boa and dsehW m sddttmod sheet nkoviq ton m of dr soAWnendan and dadr vo&=.omp.Dolky bdornmdm
f rArr agovlara ararkdis'eoatpensaBaar 6rsanurela►a!'ea►ployeea ddow b th.0ady.,.J foes star
Imtttantx CompanyName: t►�l�u�nl 1L � L��h l^cx u�
Poficy r or SelF-ios.UL r. ROu 0 0-2, )O A Expiration Dane !1 �IBC'
Job six Aaares• 4 V1 or t �a va cay/stawzip.- 5g l f—.
Attack a cc"of the workers'Wmpeasatlos Policy deelaratlos page(sbowiug the Ply Rumhe!and exptradon date}
Failure to soave coverage as required under Secdon 25A of MGL e. I s2 ceo kad 10 the imposidon of crhnmsl penalties of a tone up m S1,500.00 and/or one-year kaprisomocK a wen at dva Pe naMp m the form of a STOP WORK ORDER and a fine
of up to$00.00 a day against tke violator. Be advised that a copy of this smxment may be forwarded to the Ofllce of
Iaverdgadm Of the DIA for i Wasoce coverage veri}kadou.
I do kereyevo anJW doPAW and penahGs Nv00817 flier floes brforwarion pMAW abow is ow and ewram
SiMMUM
Pbone
[geld ass onbt. Do nest Wdu Ar ebb are.to be cowp/efsd by cAd or ma�a @hWd
City or Town:AN" termlHLltxaaa r
IUWM Au (drde oae)t
I.Board of Heald L BuBdlag Department 3.C'itYfrown Clem 4.Electrical lutpeetor 5.plug lmpector 6.Other
Contact rersoa: Mae r:
ra wc4 �.y.,.,7.....
Massachusettsto 152 roquira all amployaa 10 Pow workW contrail of here, .
purmmt a this staa0, an c General a in aw vat is defined s"...MaY Pw° 1Le savica of a°° u'
tweet or oMhe4 oral of°erg
_.,,��,.*�� tioa dr odwr heal am*,a esY mo or morn
An employ' is defined as"era mdtvtdual,Yam"""" ^ of a de cesod employer,of the
of the foreVoiog a p is a joist ealaPrite, a wmof other iedal entity,pOPIOMI employees. Howevef the
raeiver or fasten otffi Uvog>mn&n b do m wuogM e. �us��w�0o mp eo �ma
owns: g a dweilmg who cmpWs Pawn oonstrnuw fcobo deemed la be as employs.'
d on& home of«building 1PP°la��aD shall sot becatae of each empbYtnsl
err m dte gtonnde char wkhhgl/the snasw�
MCjL cbapte1152.125C(6)aW I that"Way stde or local dfaslag
for as4
raew9 of a Bewe or persll to operate a Walsall a� bw MWW K9afrsd.»
SwIcad whe>d set prodand oe"Pt le ttor my of is polttieal mbdtvmmos sbaII
Additiaaalty,btCat.chaplet I52,j25C(7)state"Nei®a ibc ao elm
emer into nay cout+ect fbf paffirm>mee of D ngauamma of is �>k0o ��y of aomPlLmoe wis tba
th chapter bavebw pnwl�
the boos that apply la yw situation�'if
Plan fin out the workers'wpemn affidavit compan dy,by char wit Ock catifials( )
anad
a)name(sl addraf(e)and pbe�e mmoba(s) s atI thaw Ale
ne csssy,ntpply (ice or Limited Liabtl[ty Piffee mbips 01,P)wi&no employee
tomnaee. Limited Liabr' W C=Wmiu boom If as LLC a I.LP doe have
members of Palmas,are not"*god nY be submitted In the DepwUncd of btdsstrtat
employees,a policy>r fe4aired Be advised that this affidsvh may
eed 9Woveraw Ahto be eve to sip and daft the aflldavk. The affidsvlt aho�id
be re d�°0aCity oO 0Of to" licatioa ke the pamit hoeose dw law OF if you m roquized towob�a
ladomtrial Aaaideos, Should you buvc OW Qs+stioas iWrdh 0 . Sew-inmrod compsms dbottht ema their
compematim policy,P>cw call the DeplRtrt>ent a>bue aloha bstad
scli inaartmee hence u.*"on the
CIO or TWO Ofiidds at the bottom
please be asn ge agldyvk is complete and printed lc&IY. The Deparhoenthw Provided a apace aPp
Hcas.
of the affidavit fttr you w fill out in the evem the Office of Inveadptiom bsa a contact You regarding
mmiber w1u�wt71 be need s a refaace nomba. 12 add*"an applicant
plow be are a 0 in the pamNticemle applications to sty given yew,need only,submit one affidavit iWicatins camrent
Pommy �,Wmnxdon(if ��"Job Site Addrsa"the applicant aLotild write-an k�catiom is (�lY v
town}"A copy ofew agidsvk i o bs bee olBctaDy stamped marked accues.A n�cw aaf of 6d�h��to
tack
applicant as proof the a valid dfidn*is on file for Alan patam of
not related b any bnsiws Of w=WCW vEnec"
yew.Whoa a boma owner 4►ettitxa is obtai )said laaw or Pamira lee Chia aft"
(it, a dog&cm of"wA to ban lava ere) pawn is NOT nqutnd comp
The Office of investigations would ttte m tbask you in advance for your cooperation and should You bsve any VWW0ts,
piece do not beasts tb give m a caLL
and fia immba
The Dees Mores addles,9e1CPBM
The CatnmonweaHh of Massachtlstw
Depmweg of lndosuW Accidents
otaoe of InvexdPdoWl
600 Washington Street
gout,MA 02111
TeL #617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-2t1 OS www.lnasLgov/dis