17 ORNE SQ - BUILDING INSPECTION use a the 8&aidt V?
wnee a tl+e urrent
Maww of®uaw Cvvyr� vc c a It dwells&how nWW ta+ib
ArdAmcft NO" —
AddnM and PhonswAddremandPhons
medwies He"
Canstrudlw Supwviaw Uryra. n 1_S'7<l S' HIC R•patrett�• /n 9 (o
Estrnwd coat aato Pr =t�°�6—T°°�a-� P«nrr<F.•c.w,=
Permit i � ' Estimated Cast X$71$1000 Reddenlal
- --- — Esl/n•Isd Cast X=11/51000 CoernsrdaL -- -An Adddtlonai=6.00 In added a•an
Adminatr•" g
Make sure that aq tbids are propeht and a01tdY`"dim to avoid do**In p vcrosln&
The widoslpn.d do"hw*W appy tear a Suiidk*Permit I to the ahow stated
spsckle WvL SWad under pwu ft Of PerAO
Date
�Az"
F o �
VJ� i Vr 3
0
PUBLIC PROPERTY
DEPARTMF.►�i r
wva. 130'Veavw�w ysYR.3K��pcsnl'fs 01!'1e
AtPI1CATI IN FORTH! RElAIR. R 1=ATM CONMCTM
DEMOLITION.OR CHANG2 O/U3S OR OCCU! >,CV FOR ANY ZMMG
t.�lfTt INFORMATION '
Laealton Name; eu9dMsg;
.. props,tyr Ad*mw---- --- -- — — --- - - - - - - --
F%oW lV Is Iocoled ins;CoA vdbn Anw YM Hk wft 174Y1at YIN
ZO OWNERSHIP INFORMATION
Zt Owner of Land _
Names �e
Address:
Tale~.. - V q- Co
sA cOMMxM THIS SECTION foil WORK IN E]It3IWQ BIJILONGS ONLY
Additlon Exlstlrg
Renovation I X Number of Storlsa Renovated
Change in use New
1Demoudon Existing
Approximate year of Area per floor(st) Renovated
constructlon or renovation
0( existing building New
Bee[Description of Proposed Work: Q
--- - ---Mail Permit to: Lip rer 144 1 a4,4 6v ,
CITY OF SALE
PUBLIC PROPRERTY
DEPARTMENT
wr4aFR[F.Y URIe[:ULL
M.\Y(ra 12C WA--94MU ON SUMT a SALEK hL\anC7 ezu t"1S 01973
TILL M745•9595 s FAX:97r.740-9946
Workers' Comp assidon Insurance Affidavit: Bailden/Contncton/Electridons/Plumben
Anallcant InformationPrint Legibly
Name tflu-4ntuKkWizuiavlmlwuh11nq
ret : L�
Addas: 02 I J r 1 tl e
City/Stam/Zip: tuft 67 2e- -
Are you as employer?Cheek the appropriate born Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a gene rap eonitaeWr and I
employees(full and/or p rt-tine).• have hired the sub-contractors 6. ❑New c°nxttuc4ou
2.❑ I am a sole proprietor or partner- listed on the attached sheet : Remodeling
ship and have no employoas Then wbconaaerors have & Demoli[iat
working for me in any capacity. workers'comp i/g �• /
(No workers'comp. insurance S. ,(�We are a ar4rreiGan atre'I'issN' 9. D Building addition
required] 9 3 6'cers have cxercwcd tar 1 .❑Electrical repairs or additions
3. 1 am a hottxowner doing all work right oroxemption per MGL 11.❑ Plumbing repairs or additions
myself.(no workers'comp. c. 152,§1(4),and we have no 12.❑ Ruof repairs
insurance requiced.j r employees. (No workers' 13.❑ Other
comp. insurance required.]
•Aeq+Pplicant the cheeks be,01 moa also fill as an secttoo telma(howina their who'cumpmuaiw pdi�y infi atioa
' Ilwnmwnws who submit dsis afrldovk indieatbra dwy am degas YI wwk and hw him eeldde cammetam HMO submit a esw atttdavil imliadina such.
:C.,mraetues dW ckvk his box muss adaehed in additional chest 4 owuy the nano of epee sphcaeragog sad thaw wurkam'co np.polity infMnmaim
i oar an employer that is providing workers'compenredon LurrraneeJorMy emp/oydrs. Below is the policy and fob site
IlIJYlmYf%Yn,
Insurance Company Name:
policy is or Salr ins. Lie.q: _ .. Etp union Date:
Jut)Site Address: - CitpstaLOZip: . .. _ .
Attach a copy of the workers'compensation pulley declaration page(showing rho policy number and espiratiun date).
Failure w wcuro coverage as required under Section 25A uf.IGL c. 152 can lead to the imposition or criminal penalties ors
tine up ut S1.500.00 and/or one-year imprisoruncnt•as well as civil penalties in the form ofa STOP WORK ORDER and a fine
-if up to S250.00 a day aguinst the violator. Ile advised that a copy urthis stawn ril may be forwarded to the Office of
Ito sn.aumis of the DIA for insurance covcrayu verification.
/JY herby cent Yn the pY s w pant/ perfY kw the informetion provided above is true ut! correct
<i•:crtier` D� d
-
zz
01jkieiYsr on/y. .I o prat write in rh/s area,jobs cumpiered by city of town off a-Ad
City or Tnwn: Permitil.leense g
Issuing Authurily (circle one):
I. board nritealth 2. Iluilding Department I. Cilyffowa Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Ptrsou: _ Phone p:
Information and Instructions
%jusachuuetts General Laws chapter l52 requires all employ �rovvi die service another employerscompensationunde any Inrtheir C of dire.
pursuant to this statute,an ewpfoyee is defined as'...every pe
eaptcss or implied,oral or wtittea"
aooe MS.omporation or other kgd conty,or any two a more
An err .kyer is de
u es imttividud.paetsmship. to er.or the
Of the foregoing engaged in a joint enterprise.and inclu6ng the legal representatives of a deceased�s However the
usoeiarioa nt other legal eatiry,employing mpl Y
receiver or trttrwe of as se having of ionsparWA hu a and who resides therein.er the occupant of this
owner of a dweltimg have laving notions thin throe mainicasinapartment or re work on such dwelling house
dwelling house of another who employs persons to do maintenance.cuosautc6on parr
or on the grounds or building appurtenant thereon shall nag because of suds enVk ymem be deetn"ed to be an employer."
MGL chapter 152 423C(6) o 4-Ma that"wary state or Beal Ikendus agesey sh"withhold the Issuance or
basisees or a eoastruet buildings Is the eommoaweakh far any .
renewal t •Ilsotase or petrels to operateswish the insurance coverage required.'
bpPU MMt wM hen tat produced aeteptatrb avideit e r the
omanoft One any of it' lined abdivisioes shall
A&Wioaalty.MGL chapter 152.;2SC('f)states Neither the cortrntaiwealshvttfence of compliance with the insurance
contract far the performance of public work until acceptable enter into say resented to the contracting audtatty.
requirements of this chapter have been p
Applieana
please fill out the workers' compensation affidavit completely.by c6eckieg the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(&),addresses)and phone nu»bets)along with their certificate(s)of
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partmea.
members am not regales to carry w�.compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this atTidsvit may be admitted to the Department of Induscia
davit shoul
Accidents for confirmation of insurance coverage. Also he suroa;slu ense is andbei n$requested. not the De he aflidavit. That tptutncnt of d
be returned to the city or town that the application for the permit
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
corn policy.ptease call the Department at the number listed below. Self-insured companies should eater their
1O° line.--
City license number on the
City or Town Offlelab
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 till in the permiijacense number which will be used as a reference number. In addition,an applicant
drat 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 locariona in (city or
he affidavit that has been officially stamped or marked by the city or town may be provided to the
town)."A copy of
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 literate or permit not related to any business or commercial venture
I i.e. a dog license or permit to burn leaves ere.)said person is YOT required to complete this affidavit.
fhe Ottix 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.
The Dcparment's address,telephone and fax number
The Commonwealth of Massachusetts
Depatament of IodusUW Accidents
Oaks,of Ievestlptlens
600 Wullingtatl Stied
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Rcvi%ed 5-26-05 www.mass.gov/dia
�o OF SALEM,- MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
3 ® N
120 WASHIGTON STREET, 3RD FLOOR
yp SALEM,MA 01970
45-9595 EXT. 380-
min FAx (978) 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 Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
The debris will be disposed of at: 2/1 S/ NF CVC�
Location of Facility
62
Signature of Permit Applicant ate
to the following FULLY complete L information:
(PLEASE PRINT CLEARLY)
P(�rf'_ r . {M i CSia-,n
Name of Permit Applicant
Pje
Firm Name,if any
i 03 C!�
Address, City & State
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.