24 NORTH ST - BUILDING INSPECTION N m O
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PLANS MUST BE FILED AND APPROVED By THE
INSPECTOR PRIOR TO A PERMIT B=G GRANTED
Locnba of sYunio�
Building PeraitAp or.
'(circle whichever appliaa Remof. Install siding,consaw Dock Shod, pod
Addition,Alteration.Rgak/RgdaM FouW&don Only. Wnddn&
othw..
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DZLAYS IN PROCESSING
To the hupector of Buildings;
The unclu igoed bmby applies for a permit to build amoM mg to dw&'UW* og apeci8ca6100a
Owned Naaaa e(`SL/E %u?L k Caatrmor. 1 Apt jja ca ed~w, �
street //a isnsrAi cT city�S' .t�1 saea �liJ, uJf / city�,�
state--/71/4. Phone 076_qVy-yam suted2t Pbooe
Archiw: City of Sdeo u
sweet City State t_BB►y ,/0b94qf
~' D Hommmen Exempt Foraa�ra ao
Steuftre:(please cirde) Siogk Family. Multi Family# �2
Estimated Cat of job S
Win boil t+g cunns toLw± a
WKnptioo of work to be 4.e
Dm w Submia d•,_yes no Man rank to:
Si nh(Ap $IGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE OMPLETED WITHIN SIX(O MONTUS OF lERMIT ISSUED DATE
Depenment use oar: P d—w--i-- zoning --,--
Permit fee s
car2WrrS:
' CITY OF SALEM9 MASSACHUS<TTS
PUSUC PROPERTY DEPARTMENT
120 W"HINGTON Smarr, 3RO FLooe
OALEM.MA OI 070
TEL (070)745-96911 EXT. 300
FAX (978) 740-0040
STANLEY J. USOVKZ, JR.
MAYOR
DISPOSAL OF DE
N AFFIDAViT
In aaordaae with the providam of MOL c 1Q,M4 I aolmowledip than a a cooditiois
of Baildift Pamir# .ad ddria rig ftm tbt cm ucdm activity
Sovemed by this Buiidiag Pa®it dM be disposed of in a properly Hemmed solid-wauw
disposal bciSty.n defined by Mt$c UL SIMA. n
11w debris wi11 be disposed of at B(T (,4/)Kk `-1��
Location of Facility
o..
f Hess
FULLY camplet I the Dowirs information
(PLEASE PRINT CLEARLY)
lezit zai
Name of Permit Appllcad
Frrm Name.if soy
Address.City A State
The above statute requires that debris fim the demolition,renovation.rehab or other
alteration of building or stricture be disposed in a pwpaly-Gceased solid-waste disposal
facility as defined by MOL dili S150A, and the building permits or licenses are to
inflate the location of the facility.
� s\ i nc a.viimsnnvcusen a��nwi�acnuxus
' Department of Industrial Accidents
Office oflnvesdgadons
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiy
Name (Businesstorganizatimiudividaan:Ta l`/�``C�—&9E&/p I
Address: J�f
City/State/Zip: Phone# 979/ 63/- L*
Are an employer?Check the appropriate box: Type of project(required):
1.U I am a employer with (�2— 4. ❑ I 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- fisted on the attached sleet t 7. 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 required.] officers have exercised their 10.0 Electrical reps or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑ Other
'Any applicant that checb box#1 mu4 also fill out the section below showing their worktrs'wrnpensation policy infornetioa
t Homeowners who submit this affidavit mdicatmg they am doing all work and Wen hire outside contractors must submit a new affidavit indicating sucb,
tL-ootmctma that check ibis box must attached an additional sheet showing the nano of the sub-contractors and Weir workers'camp.policy information,
I am an employer that!s providing workers'conspensadon insurance for my employees Below Is the policy and job site
Information. 77`1-,;00s
Insurance Company Na :me '-l6j M(jr()��1J$ l-'s / 64 : Lr,cOXAV (koL k&e , f'
Policy#or Self-ins.Lic. #: WGJ.S- Expiration Date: -6— ,0
Job Site Address: f� in
14 City/State/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 forwardod to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cent under the and penalties ofpaJury that the Information provided above true and correct
Si tut : Date:
Phou #:
O,Q7cial use o* Do not write in this area,to be completed by city or town offleiaL
City or Town: Permif/i.icense#
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 M
xxxxtyl lilfabavaa «. . _------ -- -
Massachuseus General Laws chapter 152 requires all employets to provide workers' compensation for their employees.
"...every person in the service of another under any contract of hire,
Pursuant to this statute, an employee is defined as r
express or implied oral or written."
An employer is defined as"an individual,partnership, associabM 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
of an indivi�,partnership,
receiver or trustee tship,association or other legal entity,employing emPbYas. However the
owner of a dwelling house having not more than three and who yeses 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 tbereto shall rot because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"teerye or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to m n buildings in the commonwealth
applicant who has not produced acceptable evidence of compliilli ance with the insurance coverage required."
for any
required
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor 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 ibis chapter have been presented to the contracting authority."
Applicant
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to yea situation and,if
necessary,SWP$'sub-contractor(s)uame(s),address(cs)and phone number(s)along with their certificate(s)of
Co antes(LLC)or Lmtited Liability Partnerships(I.LP)with no employees other than the
no
insurance. Limited Liabr mil non insurance. If an LLC or LLP does have
members or partners,are not required to carry workers' compensation
uired. Be advised that this affidavit may be submitted to the Department of Industrial
employees,a policy is req
coverage. Also be sure to sign and date the af9daviL The affidavit should
Accidents for confirmation of insurance
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 number on the to line.
v
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 fill out in the event the Office of Investigations has to comact You regarding the applicant
Please be sure to fill in the permidlicense number which will be used as a reference number. In addition,an applicant
that rust submit multiple permitnicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant.sbould 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves eta)said person is NOT required to complete this affidavit
The Office of Investigations would Ue 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 numbs:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 021I t
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwmm.gov/dia