9 ORLEANS AVE - BUILDING INSPECTION (2) S inq/E rGrY1� lN N� Yh� _ ,
vunac is 00 current use o1 the BuiidW ---�— 6Nl�-
Magrial of Bu�dinpT o 0 0 D tt dweMinp.how mam units? �Q
Wfr tl�e BUIdAV Confc^n to Law? y� -= Asbeabs9
AtctAsds Name ( )
Address Wd Phone
ms&mies Nam.
Ad&G"Old
gupervhorslieenM>y /fOrn�6 HiCRepMmft^0 J�o�rrE
owr� 2
C°nstrueffar D °° Perrot Fee Cala�Ntlon
Esdnuftd Coat d Proled a / Eomood Cast X=7f:1000 Resider"Penrdt Fee i EsWn1ftd Cast X$411MOO Carrrn•► ---
- An AddWMW 1&00 is added as an
AdrnMWVaUve charge.
Make sure that al flslda are PraPwiY and may
written to avoid delays In prooeesin4
The wwWniprwd does hereby q*V for a BuNdWS Permit to bud to the above stated
spearas*nm. gipped under penally at por +"
DateSO
5 } �
,1 a
5 `
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CITY OF SALE
PUBLIC PROPRERTY
DEPARTMENT
:.h\IaratF.Y UaLS(:ULL
M\Ylle 12C WASIeVI'rgYSnexr a SAtast,ht\xtAC7a.ft 1't\O197s
TILL 978-745.9595 a FAX:9MY4069946
Workers' Compeasadon Insurance Aflldsvit: Builders/Contractors/Elmrid3ins/Plumben
Aniffligant Inrormadon PleasePrint Leeibly
Name 111uainesslOraanintiWlmhv,drmll: 0 M -
Addrtss: 9 d PG C19A115 /4? UE
city/statwzip: ;41_E m /,12 1V Phone a:
Are you as employer?Check the appropriate box
Type f project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and l
employees(ruts andtur pan-tine).• have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. Q Remodeling
ship and have no amployces Them waeottrractora have V. rE�
ntolition
working for ma in any capacity. workers'comp.insurance. 9. ildittg addition
(I�o workers'comp. insurance S. Q We am a corporation and its 1- E dings required) officers have exercised thew ❑ repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152,§t(4),and we have no 12.0 Roof repairs
invite=required.j t employees(A'O workers' 13.Q Other
comp, inmru mx tequim l
•Aiq Viskast thei ehcdp boa et mast aho da out an wism itelow arowiaa their wwbm,ountpsn MkM puhty imf nentuia6
'I tLxmw,wmee who submit"amdavb Wimats they ant daisy on wart amp Mmr him ourfee ewn"am mwt submit a maw affidavit imli°rina tweh.
;CordmAue{the clock this boa mop anarlLs'in additatmtd Am LlWwiny as me t of ateA6.00aftiesMamp their wor ters'way.policy whir nertae.
l um un aorp/oyer that$provlding workers'compertradon liuuranee for my employees Bslow is the pullsy and Job site
irrforAtiff ,
Insurance Company Name:
Policy 4 or Sclr--ins. Lie.q: _..- Expiration Date:
1Jb Site Address: cuyistate/zlp:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A tit'.IOL c. 152 can lead to the imposition of criminal penalties of a
rime up its S1.560.00 and/or one-year lrnpristmtncnt,as well as civil penalties in the form ora STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advised that a copy urthis statement may be forwarded to the Office of
less Nu;,Juons ul'dic DIA for insurance covcrayc ecrificatiun.
I do hereby certify under;haZPMjj1YId penalties of perjury Oat the lafermatlon provided above is true and correcL
Date ��� 7-0 L_
U/Jlcid art only l)o net wrAr/a this area,to be completed by dry or/own o/Jh l d
City or Town: __, PcrmiNl pease M
Issuing Authority(circle me): --
1. Iluard orittraith 2. nuilding nepartincnt J. Citylfomn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Gnuact Persmt: _ _ _ _ ._ Phone p:
Information and Inst
ructions
ht,ssachuseas General Laws chapter 132 requites all employers
sstop%viservice of' compensation for another node any their
ee of oycee s.
pursuant to this statute,an easpfey"is defined as"...every per
express or implied,oral of written.
eM deyw is ddleed n"an iadividw4 P ip.assoctaaoa.corporation or odic legal entity.or-any two or tutors
An
engaged in a joiN euetpriaa and including the legal representatives of a deceased employer.or the
Of the foregoing
association or other legal entity,ernpbymg employees However the
receiver a dwcl a of m individual.pa-12011 u ' and who resides therein,or the occupant of the
owner of a dwelling hats havinfi not meR dice done of re work on such dwelling house
dwelling house of another who employs Persons m do naainteaamce,c.suck a tine Pair
or on the groun
ds or building appurtenant thereto shall not because of stteh entployrnent be deetmed to be re employer-"
MGL chapter 152. §25C(6)also states dial 'every slats Or local lie Lasing agetuy a "withhold the Issuance Or
ts the eommeaweaHh for ley
renewal of•Ileease or permit to operant a business or to eosnbruet buil with iln dings Its
coverage requtred."
applicaot who bas out produced acceptable evidence of compliance
Additionally.MGL chapter 152.$23C(7)states Neidler the cormtttomvealthvirkruec nor any Of its Political
lianca with t�nsurance
enter into any contract for ttw performance of public work until acceptable P
enter in as 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-contractor(s)name(s)'ad&v*cs)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 fie
members or partners,ads not re to carry workers'compensation msmamCe• 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 as is date he QMdavit should
be returned to the city or town that the application for the permit being requested, not theDepartment
Industrial Accidents. Should you have any questions regarding the low 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 license number on the approPriatc line-
City or Town ORkWa
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 permMicense number which will be used as a reference number. In addition,an applicant
that must submit multiple Permitilicense 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 now affidavit must be filled out eacb
year. Where a home owner of citizen is obtaining a license or permit not related,to any business or commercial venture
i i.e. is dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I'hc OI'ticc of lnvesrigatiuns would Cue to thank you in advance for your cooperation and should you have any questions,
please Ju not hesitate to give us a call.
The Department's address.telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oak*of[nvatlpldons
600 wshingoon SUM
Boston.MA Oil 11
Tel. 11617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTUEM
�,yy�l ar '�a4L
aL�+� t!G 7.�ev::�wiatsT•irt:+4 uLwtww.a t1s s.
ttit:~464 5a•F.%*9"46*4
Construction Debris Disposst Affidavit
(required for all dernolidon and na owados work)
fa mconlance with the s4dt edition of dw State Building Cad@.790 CAIR section It l.!
pae%and the provisions of M. CL a 40.S Sd,
8tailditg Pantit 0 _ is issued with the condition that the debris resulting loom
this wort shall be disposed of in a properly licensed waste disposal facility as dented by MOL a
Itt. 9l3"
The debris will be transported by:
o 'IS , (O ccsk '-
,aom.oY hooted
rho&-brim wilt be disposed ariiyn :
/vO r Si Ck Ciq r h
(n,usfe uY YxtGty)
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EITY-OF�-, X
PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR T= pAIR. RESERUNCTtiltz OR L FOR
NOyA'TiON CONDUCTION
D
1.0 WM INFORMATION
Laeatlon NarrNe 65 % euy + :Property IAAIchvss:,-
`•
--- .
Property Is loaned in a:Cwmvsdon Am YM_LL F1Miorb Ct�trlat YM��
r
of Land 97 9- 2yy-/66
3A COMPLETE THIS SECTION FOR WORK IN EYIsnaip WILDINOS ONLY
Addition Existing
Renovation C'A7l' Number of Stories Renovated
Change In Use New
Demolition a iE I;n y (yAR/9GC
mo�p� ayos fr 39d
Approximate year of Area per now(at) Renovated
construction or renovation
of existing building /%S/ New
add Description of Proposed Work:
e19777 u n IPo 0 w7 &Iel
a skyl5 �ts �nr/1Sf�� r' r �1116196-,
'•�S�`� �/ $ u ¢� 7t,an7 i q G'argcfE For- A4a/0 h�o �ibrES
--- -- _-Mail Permit Im #:4- 9- ORk�grv5