237 NORTH ST - BUILDING INSPECTION (6) a
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Id PFXJ.0R PFIICIR TP A.PERMIT BF-ING GRANTED
CITY OF SALEM
�N (,11 p/ oS
Date
Is Property Located in Location of
the Historic District? Yes_No Building 3 ti
Is Property Located in �/
the Conservation Area? Yes_No X
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Instal[ Siding Construct Deck, Shed, Pool,
Repair/Replace, �he
aar`, a
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID D LAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: 11
Owner's Name �eWS t ac-O%A�
Address & Phone a3 -� /i S-�•
Architect's Name U Q
Address & Phone 1 1
Mechanics Name L I A 4
Address & Phone
What is the purpose of building?
Material of building? o If a dwelling, for how/many families?
Will building conform to law? ( a S Asbestos? / �A
Estimated cost � City License a N A State Li ense 8
je�� Hose Improvement
Lic. 9
��, Si nature Applicant
(I SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE i
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MAIL PERMIT TO: d s �ta�cow
No. v
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
20
APPROVED
I PECTOR F BUILDINGS
s
CITY OF SALEM
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The Commonwealth of Massachusetts
Department of Industrial Accidents
g/IICBelinvesUgadens
600 Washington Street, 7 h Floor
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin ` lumbin Electrical Contractors
A hcautmformahon. ��'PleasePRINTI ibi ti x,_., >
name: p_k�zu-o.0 C O Wes.
address: n�' ✓� d� e�
city SdXGAJ` state /V\.A zip: d`00O ohone#
work site location(fall address): 5 otoaae
® 1 am a homeowner performing all work myself. Project Type: ❑New Construction®Remodel
_® I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
❑ I am an employer providing workers' compensation for my employees working on this job.
Company name:
f
address:
city:
insu nee co.
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
cam: phone# - v ,[
insuranceco:
comnanv name:
v.
address:
city. - ohone#:
insurance co. - tic # -> z
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereb certify under 1he ins and penalties of perjury that the information provided above is true)I land correct.
Signature�I ,= Date `pL L C)l n7
Printname \\�a Phone#__t��' �2{�^C{.Q Ou
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
Gevisnd Sept?OiIJ)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 ajoint 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 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 152 section 25 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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, 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 this chapter have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 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.
City or Towns
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 permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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 Inllesggations
600 Washington Street,71h Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406