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23 NORTHEND AVE - BUILDING INSPECTION fl1tM64A1f16ti�EflL£jp#ND APPROVED BY 744E lwx.= 1B PWOR 7DA.PE 3VJT BEING GRANTED CITY OF_SALEM No. 9D-0 \ Data /U G S Is Property l.00atad in Location of 3 /Uno um Wr Aft DWI"? Yas No� sui ldima A-zx Is Propwty LOCONd in ft Camrvaton Area? Y=No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, C"WtW Pack. Shed, P004 Ragw/Replace, Other: PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSWG TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name 2r;t4lj2�- Address & Phone d2 3 /Uo y o/ / �l cl� j 1 2-L 5-- -7�3 Architect's Name �/ - Address & Phone Mechanics Name 17�i Address & Phone 9 What Is to pumom d tarudlrq? AAmm w bui mv? 0—Fj-0-"( n a awWV,for now many form"? NAY aiWQ Cordom to law?_ J AabWm? EfYmxW code U v uowrw r N A stag r hate. lmpr<aw�t `. Signature of Appli SIGNED UNDER E PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE �rvclC�le f C,��cC C� l cc� hz1 GPiL - 0/Y 7/-a CPS �i o✓ �z1/a7,g/ / — L-e- y 71 /y Sl ems/�ln- 2 0. MAIL PERMIT TO: No. APPLICATION FOR PERMIT TO LOCATION PERMIT-GRANTED s AP VFD INSPECTOR OF BUILDINGS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Alpyficant Information / / Please Print Leeibly Name (Business/orgaoization/Individual): L G� A114 Address: �� S 2 /cC 9 � i G✓✓�QJ S C �i� City/State/Zip: 2/ Phone#: ( y �k ) q•2- 2- 5 Are yo as employer? Check t�propriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6• ❑New construction employees(full and/or part-time).• have hired the sub-contractors 2.El I am a sole proprietor or partner- listed on the attached sheet = ?• �emodelmg 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 ME] Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LE] 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' 13.❑ Other comp. insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their worker'compensation policy information: t Homeowner who submit this affidavit indicating they are doing all work and then hire outside comrctors must submit a new affidavit mdicating such. tcommetor that check this box must attached an additional sheet showing the name of the sub-o mmictors and their worker'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andiob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date:Job Site Address: -2 3 Iv, i l City/State/Zip: C n i� 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby ce unde the paths and penalties pe that the information provided above is and come S' ature: Date: z Phone#: S Off kid use only Do not write In this area,to be completed by c&y or town o,�?claL City or Town: PermiULicense# 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#• imio 'matiV11 UHU 111a61 Ua,iiv113 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emplbyees. 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 joint 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 therein 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 construct buildiags in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C( )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 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(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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 Department of Industrial Accidents. Should you have any questions regarding the law or if you are required in 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 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. In addition,an applicant that rust submit multiple permit/license 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 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 roust 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 etc.)said person is NOT required in complete this affidavit The Office of Investigations would hlce 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 5-26-05 www.mass,gov/dia P A A PROP W DCP M IXT 128 NN "Im�MAAaiOHff PLO" _ laLs� �lO Tat.(jr /At lrf�7pN{A 40 sV.«WwVWMWV a. 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