19 OLIVER ST - BUILDING INSPECTION (5) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
WY
TO.;M745-9599 a FAX 97&M."O
Woriters' Compensation Imnrance Affidavit: Bad&WC
Applicant Information ontraetorsEePeIM 1cta ay/p f**mpen
Name
Address: LS
Cityistatemp: V,U MA- 01872 Phone* 4'1 S- 265 -7Z s�
Are you an employer?Check the appropriate boss
I. 1 am a employer with ZS 4. ❑ I am a poems contrsctw and I Type of Project(required):
employees(M and/or part-time).* have hired the sub.-conaactare & ❑New cmatmction
2.(] I am a sole proprietor or partner, listed an the attschad sheaf,t 7. ❑Remodeling
ship and have no amployeaa These atb coatreceoa have 8. Demolition
working forme in atsy eapscity. workers'comp,insurance.
[IVo workers'comp iasuranq S. ❑ We am a uupoation and its 9' Building addition
required.] oSi¢ma have exercised thane 10.0 Electrical repairs at additioy
3.❑ I am a homeowner doing all work right of esernption per MOL 11.0 Phunbing repein or additions
myself. (No workers' comp. C 152,§1(4),and we have no 12,0 hoof mpaia insurance 104�]t employees.(No workers'
comp.Wourance required.] ' 13.0 Other
��r wv�a dr ehedos lore rl mr steo Imam floe seeder bdow lowing dwlr waeaa• tP6eArlaaa►
ttamwwom wW=baft ibis zMdwk aatums dwy dokg eg wank=d tbo tie otesids eoaeurae PatIIdavit bsdleetftr sao�,
tcoae. .do Ank dW boa a m asebw a sdmmudv Area s6o des dw ems of dr mb Par aaestt a eransetan and dwtr wakaP•eamR petiey b»waraa
aa
fwot/ow.an employer that f:provtdlnr warRan'cowpenseden
ln or insurance for my employees Balms is the policy and/ob sip
Insurance Company Name:_ � r n
Policy N or Self-ins.Lie.#Q kJ (3 Nt- S 7 Y-Z
Expiration Date:
Job Site Addreac_I [--1l wef City/satemp: i,� ^
Attack a Copy of the workers'compensation policy declaration pap(nice the
Failure w secure Covers err �g Policy number and esptratlon date}
p requited under Section 25A of MOL c. 152 can lead to the imposition of Criminal
fine up to 31,500.0o and/or one-year imprisonmcnt,as well as civil penalties in the form imof a STOP WORK ORDER and ofUna
In es ig bons 0 a dry Afor'the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for' coven verification.
/do hereby carat a end Pe of perlwy that the Informa/on provided above is mue and correct
Phone M
00cid use onIA Donal writs in this area,to be completed by city or taws oQ cl&d
City or Town
PertalULieeme r
Issuing Authority(circle one):
I. Board of Healeh 2. Building Department 3.City Clerk 4.Electrical Inspector S. Plumbing Inspector
&.Other
Contact Person:
Phone*
Information and Instructions Massubuseea General Laws chapter 132 requires an employers to Provide urorkers'compenast fsu otLite.
Pursuant to this statute.as a�l� ed to defin as"...every person is the service of another under say coaaact
express at impUA oral or wrinee" at any two or mere
or other lead entity.
An ewpfoY r is defined so"ass individud.Pate�rP� �oration s of a deceased CoVln�weva the
of the foregoing engaged is aloiat enterprise. anociatios at other legal entity.empimYiq emPlaYea
reeeivac s austee of as ind►vtduaL Pip' sad who resides tberdti.s the tranpant of the
Nauss hart no astir+then d de mai tmeou err wodc as such dwelling bwms
owner of a dare off enO�on re m m be as empbyar"
dwalt a bouse of amthar vho amPlo>K shall not btxaues�sueh employment
or building aPP�°e thaem
s on the gtotmde also qua thu"��state er beat il�afag agency sM w��tba W for
V chapter 1 o"or�a to operate a l of esspdann h�CeY�W req�"
apptleaet tvhe bae not prodoeed aexeatatOe id"911 Ot the MPUM SwMb .any of im political st►bdivtdene shalt
Additionally.MGL cbaPes 132.per,&cimm h evidence of compliance with the inautanma
�pubik work until acceptable
enter into My ot 6e�� bin Presented to the contracting suthoft"
APPlICaate to sieadonand.of
affidavit enmplatdY.by�lOag the bmxa that apply Yo'a
please fill supply guhocontrecout the compensation
a a�addtw(a)and Pia°Partnerships(LLn`s�t* emP/oYcaumber(s)along with their )other dim the
of
�. I Liability Compaaia(es 1 or Limited ability
nol required to carry tea.compensation insurance. If m LLC at ent dos haw
member or putaw
1.is Abe Be advised that this&M&vit may be submitted w the Department of lndusaiil
employee. coverage Abe be sun to sign and date the a8ldsv% The affidavit shDepartmenould
Accidents fs congrmadon of insurance tar the permit err license is being requeded m obtain a w
be returned Ymti my moons regarding the law s dYon an required
irk"l Should hose call the Deparm►ane the ennnioriza�nemba<listed below. self-moored companies should eater their
compenaamm�Policy.P
self-hnoramce RGO&M
City or Town Odfdale s e at the bottom
Please be sure that the affidavit is complete and primed legibly. The Department aranent has provided spar
of the affidavit for you to fill out in the event the Office of Investigations as
has to ncetnu you regarding the applicant.
Please be aura to t711 is the permitllkenae number which will be used ss a reference number. In addition,ic appg Current
licsdone is any given Year,need only submit one affidavit indicating current
that must submit.multiple patoWlic�° Job site Addtesa"the applicant should write"an locations ia---(citY e
policy information(if naeessary) under staatped s marked by rite city or town may be provided m the
town)."A copy of the affidavit_that has been off
or licenses Anew affeduvu moat be filled ont each
applicant as proof that a valid affidavit is one file a icftiaae Farmed erne related to my business or commercial venere
year.Whets a home owner of citizen is obtaining a license s NOT r
m burn leaves etc.)said parson is NOT required m complete this of![davit
(i.e. a dog license or Permit and should you have any question.
The Office of inveangsdons would like to thank You is advamee for your cooperation
please do not hesitate to give us a caU
The Department's address.mkPhane IU weslth of Massachusetts
Dep"Ment of l &sUid Accidents
OIBa of 1MY"dPdoog
600 W8311i080On Sorest
Boston,MA 02111
TeL #617-727-4900 Od 406 cc 1-877-MASSAFE
Fax#617-727-7749
Rovised 5-26-03 WWWjnuLPV/dig
PUBLIC PROPERTY
DEPARTIViENT
1:1\M�11 N Ot15GULL
Mwroa 120 WASMNa"s'raF=•Smaa 4%LA�&AcHLSL1-a 01970
14i 97S-70.959S 9 PAM 973-740-9M
APPLICATION FOR THE REPAIR- RENOVATION CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: clOI i54, Building:
Property Address:
lci O1iv� � .
Property is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: /vl c r 7 t` ,o� A
Address: r 1 �� S (<--'V\'
LTe=iepne-
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation New
of existing building
Brief Description of Proposed Work:
------ ---- 4/S
Mail Permit to: Fcr�Q; ft d . tb d i MA
��s�z
What is the current use of the Building?
Material of Building? if dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone )
Mechanic's Name Le ti,. cv;, rs Sc f(ri.s e
Address and Phone LIS v-�tiL( 61A C-,L 3 2.
Construction Supervisors License# ��' ��y HIC Registration# Zy-7 7 7
Estimated Cost of Project$ y Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to b t the bove stated
specifications. Signed under penalty of perjury
Date
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CrrY OP SALmA
PUBLIC PROPE W
DEPARMIM
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Com&uc&a Desirfit Dbpd4d Affidavit
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BOARD OF 51.114 NG.REGOLATIONS 1 ,,
Lhnye: 014STRUCTION SUPERVISOR ; 7
Nurtj 089839 ,� i '
' 3 008
SCOTT P°HOU
8545ROADWAY� ,�"'r`r � r
H,4VER1411 MA 01932' -co�Ti&s1 'i
�^. ..._ �/+s 1°noarrsraaoeuiea� o�✓�ama<a/suaelta
Board of Building Regulations and Standards
HOME;IMPROVEMENT CONTRACTOR '
Registration"129774 -
� F4ptlatJ6n. 1-1f212007
t S' _TYPe 0, - -
PELLAWINDOWS°A I_ -;11
SCOTT HOUSE
45 FONDI RD. H
HAVERHILL, MA 01832 Admiuistrator