6 OLD RD - BUILDING INSPECTION (2) S t fLaD4A9 ApMOVED BY TWE
JOISffKC=P40R ZD A PLOW aEING GRANTED
CITY OF_SALEM
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BUILDWG PERMIT APPNCATION 1109h
wand to:
(Carol•whMmww apply) Roof areoHSat41 Skft C anal Dsok Sled, Pool.
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PLEASE RLL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersiprwd hereby applios for a pqm k to build aocwft to the fobwmV
Owrwt•a Nam Z255Ftc-
Addrou A Phorw bl 6 IZ- M -7ql - ik85
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Address lE Phone j 1
Mechanics Name 14mf_
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SlpnaWn of Applicant
9XI NBO TINDER THE PENALTY
OF PE LWM
DESCRIPTION OF WORK TO BE DONE
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APPLICATION FOR
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PERMIT GRANTED ?
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DO " OF MALDINM
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CITY OF SALEM� MASSACHUSETTS
?� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
gr, SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
C 47 L�
Signature of Applicant
Date
The Commonwealth of Massachusetts
Department of InduaWd Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Elediridans/Piumbers
Atlnlicant Information Please Print Legibly
Name(BusinessforganizationQudiviidnat): How—
Address:
22
City/State0p: lA Phone#: 7 �'5&q - 5 7
Are you an employer?Check the-appropriate boa: Type of project(required):
1.® I am a employer with (�_ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (fan and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- . listed on the attached sheet t 7. ® Rca;odeLrog
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Budding addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
t
insurance required.] t employees. o workers'insurance required.] 13.❑ Other
Any applicant that checks box#1 must also fill out the section below showing their wot bus compensation policy infbtr 4
HOmeownes who submit this atEdevit indicating they are doing all work and then hire outside contractors must subunit a new atEdevit indicating such. .
:ontmctors that check this box must attached an additional sheet slowing the name ofthe subcontractors and their wmkes•camp.policy informatim
am an employer that is protvding workers compensation insurance for my employees. Below is thepolicy andfob site
2formatiat. n
isunance Company Name:
olicy#or Self-ins.Lia M C5 R C 7 /Q Expiration Date: _p
ub Site Address: City/StawLip:
Mach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminalpenalties of a
ne up to$1,500.00 and/or onewyear imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
Fup to$250.00 a day against the violator. 'Be advised that a copy of this statement may be forwarded to the Office of
westigations of the DIA for insurance coverage verification.
tlo hereby cerBfy under the pains and penalties ofpery'ury that the information provided above Is Arne and ear+ect
mature: Date:
cone#
QQrcicl use only. Do not write in this area,to be completed by ci(v or tram gj)Fcid
City or Town: PermWsAcense#
Issuing Authority(circle one):
L Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M