15R NORTHEY ST - BUILDING INSPECTION fL�NSir1UlST�Ef*jI184019 *PPROVEO BY T44E
uLyx=PWOR TOA.P.EW BEWR GRANTED
CITY OF_SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Roqok kudall Skllr% , Constnot Deck. Shed, POOL
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PLEASE PILL OUT LEGIBLY i C=Y TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersig wd ttereby appim for a perms to build according to the following
Owner's Name
Address& Phone (ZT14 Sf LM qa-77- 9058-
Architect's Name
Address & Phone L )
Mocimics Name � e)w) 6 1 2(GGgs-,f2 ,
Address & Phone R R
WtW Is tlts purpm of butldktp7
Idd"a buWYrtp? �- )& )I I �1.� ll V R �omwe.br how many Ia on?
WN b mwo to I"? M mws? 1 g )
EdYnsMd cost , ` () iLlosrtw r N 0' amr
tc. f Signature of Applicant
SMW UNDER THE PENALTY
OF PERJURY
Q=R OF WORK TO BE DONE
L
MAIL PERMIT TO: " t4
L,( Cop) [•X 11 b
NO. -`?
APPLICATION FOR
PEFVW TO
LOCATION
PERMIT GRANTED
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INSPECTOR OF BUILDINGS -
i
CITY OF SALEMV MASSACHUSETTS
i. PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEm. MA O 1970
TEL. (978)745-959S EXT. 380
FAx (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Pemrit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S 150A.
The debris will be disposed of at: ocreC£4'-ne�
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
9CXA-)1-j (2-14 Hots
Name ofPermit Applicant
{{
Firm Name,if any
LL 0 2C�s-TE' 2
Address,City& State
The above statute requires that debris from die demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
r
The Commonwealth of Massachusetts
Department oflndusoial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plambers
Applicant Information Please Print Let ably
Name(BasinessiorganizationQndividuat): H orn f! _ J�nc DoT
Address: 6L[tJ m£f t r u soo, � Q
City/State/Zip: OR Cf�iTi {� Phone M 17 8'rJ b q -5-7(-o ,(o
Area an employer?Check a appropriate box: Type of project(required):
1. I am a employer with 4. ❑ 1 am a general contractor and 1 6. [:] New construction
employees(full and/or part- ).• have hired the sub-contractors 7 Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet t
ship and have no employees These sub-contractor 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.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself[No workers' comp. c. 152,§I(4),and we have no 12.❑Roofrepaas
insurance required.] t employees. [No workers' 13.❑ OTker
conw.insurance roquira]
Sny applicant that checks box#1 must also fill ow the section below showing their warps'compwsetion policy fi formelion.' _
Homeowners who submit this affidavit indicating they are doiag all work and then hue outside contractors must submit a now affidavit indicating such.
;ouhaclors that dwek this box must attached an additional sbeet showing the panne of the sub-oonbagms and their workers'comp,policy information. .
am art employer that isproviNng workers'compensation hsunarcefor my employees. Below is titepolicy andfob site
formation. 11
tsarance Company Name: L &E- RA
alicy#or Self-ins.Lic.#: raqot 41 Expiration Date: !:�2
tb Site Address: City/Stateizip:
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
blare to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
'up to$250.00 a day against the violator. Be advised That a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification,
to hereby certify under and penakiens of jury that the informadon provided above is true and correct
I Mature: A Date:
tone#:
Offwlal use only. Do not write in this area,to be completed by city or town q,BFcld
City or Town: Permit/License#
Issaing Authority(circle one):
L Board of Health 2.Building Department 3.Cityirown Clerk 4.Electrical Inspector S.Plumbing Inspector
C Other
Contact Person: Phone#:
Information and Instructions
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 tie service of another under any contract of hire,
express or implied,oral or wrium"
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 aparunents 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, §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 buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage 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 this chapter have been presented In the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes fiat apply to your situation and,if
necessary,supply sub-contractor(s)name(s),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 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 licence 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 fffi in the pemhiacense number which will be used as a reference number. In addition,an applicant
that must 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 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
l'he 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
vsted 5-26-05 www.mm.gov/dia