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92 ORNE ST - BUILDING INSPECTION (2) r ode Is PNMIV LOW"in lb PKJPSV Laos" a oLuam raver MWLArAIM Fora Ckdo wo lW-F&OW cones osak. DNA Pool. wIWF"=urmyaoo rAmlToAvaila"rswvwocaiMM� To THE RS*Mw=OF ems' no hw* NOW w a PW" q pWld aooadinp to tl» WAWA" ownws Now L� S !'�1 2 /''�rn o ,�f AOM IL Ph= Address•Phons kis"im NOW Ad*s"• Phons z4�o14tn St VAM is sr PPW it e~ memo a art •erMlno. now o�ll los�aoo4—.--� wr�rdrq saross o�rwR Idwa a sit A D D Dom, ,Cw Lbw • N A so um"oy 44 �r!tf C S p 7 33'T X4n�lim� Z i'YO�fk TY �p{Na/It TiiE PiNA� oppomw OlSCrpnoN OP v1M TO of DOME MA L PERC s APPLICATION FOR PEMW TD LOCATION �0L 0 r^e PEFWT 1NSP6 OF BU&Dpw CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET. 3RO FLOOR SALEM. MASSACHUSETTS 01970 STANLEY J. UBOVICZ, 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) lam- 4 ll Signature of Applicant �© Date The Commonwealth ofMassaehusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridamffllumbers Applicant Information t { ) 1—Pleaasse Print Le�bly Name (liesisessror�nization/bidividual): B IZ�U 1� 5- 1- c VU n -f- 17 Gt I� Address: 1'ZN6-1 4n St City/StateMP: 17�t v� v e =.`.�u Phone#., T L1-�3 33---) , Are you an employer?Cheek the ippimpriste bms-` Type of protect(required): 1.0 I sun a employer with--s 4. 0'I am a general contractor and I 6. ❑New construction employees(full and/or part-tine).' have hued the sub-C tntractora 2.0 I am a sole proprietor or partner- listed on the attached sheet t 7. ® Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any.capacity, workeap' comp. insurance. g, (� Building addition (No workers'comp,insurance . 5. ❑ we are a corpo atlmi add its'' 10 D Electrical airs or additions regaired.l officers have ex'cised then' 3.❑ I am a bomeownerAoing all work right ofexemption per MGI:' 11.0 Plumbing repairs or additions myself. [No workeW.comp. c. 152,41(4Y,"and wehave'no . 12,0 Roof repairs insurance regnired y t. employees [Nq wO kern' comp.insurance 13.0 Other «1nff r -Any epplicaot the checks box f I must slab fill out section below showing their.,wo>l a'eo,"ntion polky rohanstion, 1 Homeowner who suh®t tha•'affidsvit mdieetmg they er dams all work and tten biwoulaide coaftwtor raist submh a new affidavit indicating such tContrcWr tilt check this box'muat d9whed no edditiomtshe&showing tM nmm bf dm sub•cw�and rhea wmkets'comp•policy nformanon• I an ati'employerthat is providing workers'coarpeasadon huurance for nay i4loyesm Below is the polity and Job she informatim Insurance Company Name: 17 0h6 e-1-& Policy#or Self:ins.Lic #: Expiration Date: /P Job Site Address: City/Stateft: 5Ct,&/L— Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failtire to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against tie violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby cerdfy under the pains and pens/des ofperlury that the informadex provided above h true and correct shmat im: Date -�Zfi D D 6 Phone#: 9 7C — 7 9 y ^ 3 3 O leld use o* Do not wrhe/a this area,to be eomp/eted by city ormm ofjJciaL City or Town: Permif/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Ckyfrown Clerk 4.Electrical Inspector 3.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions ter 152 requires all employers to provide workers' compensation for their employees. Massachusetts General Laws chap contract of hire, Pursuant ro this statute, an emotoyee is defined as"...every.person in the service gf another under any express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation dr other legal entity,or any two or more engaged:in a joint enterprise,and including the legal representatives of a deceased employer,or the of the foregoing engfa artnembip,association or other legal entity,employing employees' However the receiver or Onisue of an individual,p and who resides therein,or the occupant of the owner of a dwelling house having not more than three apartments dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house thereto shall not because of such employment be deemed to be an employer." or on the grounds or building appurtenant MGL chapter 152,§25C(6)also stater that"every state or local licensing agency shall withhold the Issuance or renewal of a license or permit to operate it business or to construct buildings in the comwtonwesi*for any applicant who has not produced acceptable evidence of compliance with the insurance coverage regions shall "Neither the commonweald►nor any of its political_ 152 25 states"Neither_ Additlonally,MGti chapter +§ �� table evidence of compliance with the insurance work until a enter into any contract for the performance of public coo � requirements of this chapter have been presented to the contracting authority." Applicants the boxes that apply to your situation and,if Please fill out the workers' compensation affidavit completely,by checking with their certificate(s)of necessary,supply sub-contras)name(s),addresses)and Phone number(s)along with no employees other than the insurance. Limited Liability Companies(LLC)or Limited Liability Partnersbips(LI members or partners, are not required to carry workers' compensation insurane. If an LLC or LLP does have employ a Lucy required Be advised that this affidavit may be submitted to the Departm� al t of Industri ees, d date the affidavit The affidavit Accidents for confirmation of insurance application tverage. Al:so bet,: itoI licenssure sip e�is being requested,not the Departmenshoonld be returned to the city or town that the app p the law or if you are required to obtain a workers' Industrial AccidenM Sbould you have any questions regarding the number ljstcd below. Self-insured companies should enter,their compensation policy;Please tail the Dep-wUnent at self-insurance lictnsei»mnber on the to line. City or Town Of6ciela Please be sure that the affidavit is complete and printed legibly. he 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 permit(license number which will be used as a reference number. In addition,an applicant cense applications in any given year,need only submit one affidavit indicating current that must submit multiple permitti information if necessary).and under"Job Site Address"the applicam should write"all locations in the or info ( be provided to policy ed or marked by the city or town may town)."A copy of the affidavit that has been officially stamp applicant as proof that a valid affidavit is on file for future permits or licensee. Anew affidavit must be filled out each e or permit not related to any business or cormnercial venture year.Where a home owner or citizen is obtaining a licens (i.e. 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, The 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 Revised 5-2605 www.mass.gov/dia