12 1-2 OSBORNE ST - BUILDING INSPECTION (2) StFI
=F==POOR TOA.Pl WNANO aRAWkD
No. L-4 CITY OF SALEM
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Pannkta BULDIG PPOWAPPNCAlM POI!
(Chb MMohawr apply) PAd Rwd InMaNa SWft CWWJ k Ds&.. Shad, Pool,
PLUM ML OUR LMLY a COMPLETELY TO AVOW DW AVS M NWCW q
TO THE INSPM"M OF VJWNM- '
hefty appW tot a Wmk to blld aooad%to ft.tolwj*V
speoraeftm
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A*Wu a Phone Vl k Nj 044r1-rvi P- Pr m �1.,� `1'1°►sr
*&&af Name
Addmsa A No t
Modunim Name
After a Phone t t
vas r rM wvoaan OWar,ot
ktaft d mmig7 N a 4,for hew mprj 1wlil�t
End Z��al►Uon1N� alb Lnollar• _ C9 ��G�S
SION�D INIDEII THE PENALTY'
OESCRPIION OF F WORK TO N DONE Olr poutm
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MAIL PEFUT TO:
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APPLICATION FOR
PEnmrr TO
d
LOCATION
Id-,�- d s�,/>
PERIAT GRANTED
INSPECTOWOF BLXL.QIE+M
CITY OF SALWAS fMASSACMUaiKWS
PusuC PROPt{t171f DCPA MSNT
t m VAU M IUs7 R sms"' Sao Roos
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ram c07417194afat; tier.300
Rna (970 74046"
STANUCT A U80VIC36 .us.
MAVOM
DL4 CM OF DE8U AFMAVU
b sooasdseoa�the psovtiaaa a[1dQ.a�q�I the�a eeadidos
ot9aild6t!>,toit r .a•dshda ntsslties fos the oeassuedas aes[.ihr
IP by Fain*sW be ANPE d offs a po"lyr rieaaasd soE+.wada
dlsleul atei>iq�r dadbta�l by 11Q.s)a.!IlOIt`
7W d"wit!bs&posed otsft
.,/�� Laeaslaa dFadiigr
offtmit Applieasa Dana
FULLY emplaei as knowing mbez" m
MLEAS31'RW CLEARLY)
??=a of Fsemit Apptled
FiisMama,itsgp
Aar CW s ada
ns,bow,tsars roWIS that debris ass td dsmohdo%raoovsdM rehab or other
aka mdom otbulft a,!;&rase be di--A is a peoparirBeeosad soU&wsw disposal
&c ft as&&@d by II M cdAm stSQlfw,and the baudfnspsrmita or&"a as to
WdkW dw Ioe "of id Aloft.
i
i A"Pannsuu of inonstrw neaaenis
Qf'iee ofInwi Yddtioas
6M Wuhinaton Sbrd
Boston,MA 02111
tvwtrciltusaotd8e
Workers'Compemdon Insurance AM&vlt: BWMemContradomElatridan ffllnmbels
ADDHeant Intormatlol >h
NameMa&=KkrWnd=&MvidnWR�iS'�ivAvl sin, S �� �ti�
Address: I// erfmzz —
CitylSta &7* a gAL4- Phone 0 9 ��f5° �b D
Amy m employer!Ckeek ft Wraprlate boss
1.E 1 an a empl ya with 4. 01 am a aemwd wMaaor and I °dproJeet(regairedl.
empbyeca(ta and/or pa -time).* bsve himd the 6. ❑New consmactiam
2.❑ I am a sole pmprieoor or partner- listed OR We attached sbeat t 7. ❑ Remodeti q
ship and have m employees These N1b eoNttactor have d. ❑ Demolition
vwddoB fbtrme in may capscih. workers'oomp.imminmes, 9, Smiting addition
[No worker'mmip.mmusNoa S• (] We are a corporatfm grid id
ofilow have esexcisol di* 10.Q Eleep�jcal rqaks or addition
3.❑ r=ash mwwow bobg all work rim oteumpdom per mm I I.O Plumbing rephs or additions
myself wow
c 13 1 4
[No eaDmp. 2,# ( 1 and are leave no
12
iasmmoe required.)t em4byecL(No soulless' 13 Rootrqmas
OMV.immana requued) 13.[] Other
;Any apPH0100 tkn cloft Lax/1 rat tiro®I oa tkr notice below wwas 4Nr vAdwW
Homeowrrr Mo abmk W afEfdrvlt adicafts dwY m dote{a0 walk cod am*8 aalaidr aoatretm=0 tuba it a xwx yw afflayk=&Mina rook
tCaotraeton At ebaek fiir lrx mot attar>rad a additional atrn�aw'ma fir nor of tin aoDanteuyge and�w'ohawa'aamy�ydky iofoiwwntlaa
I rbat 60,o►�/wg wvrksrs'eoatprw,.Har brsarmee jor sty e�vlora+ Blow b ibeOolkj awlJob atrlr
rttsmaNce O�yName:
Policy A or SeMims.Lio. tt� Erpuation Data
Job Site Addsas: City/S .
Attack a copy of the workers'eolmpemsadlon policy declaration page(dmvbg the policy Number nod espiratton date}
Fannie b segue novenae ar MAW anda Section 23A ofMGL a 152 cam lead to the imposition oferio®a!
fine cep b$1.5W.o0 and/or oupyear imprisonment,as well ar civ>y penalties of a
of up b$230.00 a day against the violabr. m advised in that a Pe�hka m die form of a STOP WORK ORDER and a fine
Im esliptioms of the DU for imoraoce covelagis vaif mdm soPY of this statement maybe tbrw9lded b the OlSce of
I As berebyec ray atssiw rbePAW MdpmdA"el ry Aso tAe IN&wetioa ynrvl&/abonr b>rrr and enrees
97J- 7?VY-
01kiduse&* Do ant writs bs Ah and,to be towplefd by d&o►m m o,Bfeld
cityor Tows: PermillUcease o
Will"Authorky,(drde ones):
6.Oth
I.Board of Stealth 2. Building Department 3.Clty/Pows Clerk 4.Electrical Inspector S.Plomblog Inspector
er
Contact Fa &. Phone ll.
Ma sachusetts net 152 Taquira all muployets to provide wotkas' to wms �••vftsi ••
Gaetal Laws chap " in the service of ssodw under any contrad of hue,
PWMU nt to this Mum a*ssipl yes is defnad as ..•Cray per°
c4resserr implied.use of"mttmo
cooperation ar otba legal entity.or aY two or nose
An Mpl&yff s defied as"32 individual p�� ���mmiva of a dectssed emPbYa,or the
of the fore mW�1sajoillcmr,d P �aspeiation or otba Iedal muff. or the ooatp���t�
receiver or ttutass of an sad who raids
owner of a dwelling boWwhowbo empbrys p t d m to do mmsmsnoe.cons of rep*wo*as sacb dwa�boost
and m tbeg boom of a &seW shall sot became of ouch®pbymmrbt deemed a be ss+anpbrya-
in agency AM
SION
MGL c u*W 152,125C(6)deco states tb� . ecco" p w�` to sf or
to eomama.►eatlh for w
renewd d a Beaus or
P to° isde evldoee d wtth tfte Wow"
e VWW ro9alred."
SU
appYeaat w►o W fast p �u Neitbc a oo °0r my of�poWed subdivisions
Ad idooaft,MOL chaPmt. ofpublic work umn acceptable evidence of cMMPliseoa w'dk the inauaeot
Of dopter boe ptamted to ac comet M&OW
thebola that apply d ytnt ��'
Please fin out &0 Wolkess
•eempematioa af6dsvft comPId*,by chee�i s du their oatifear s )
es n�( s of
necassoy,supply s)naare(s) ad�asO p elk s)aksug other thaw the
uosarsocs• Limbo laabr W Cow( �a I angled Liaht�itY Parmeish�Pa(I.Lp) no emPbYea
aubera or IN ruwM b �, �a m If an LLC of LLp does bave
a� °� c ry be submitted to the Department of lid WUW
employees,a pobey is required• Be sdvisad as this d6davit may 811�date the affidavit. M af6dsvit Should
bAe renuned to the m"'°fbwxrmw ,.vcmgg Ain be We to Mien permit or l ocuse b berm regaested..oe the of
the law or ifyon at required to obtain a workers'
InduwW AaMeWs. Should you bavt any questions below. Seif-inured aomptwia
at the numbs>� should outer tbeu
wwautionpoft pups can the Dept line
selfinaorsnc.6eeme anmba on tba
CM,or Tows Odki& ,�a<the bottom
please be sure that din a@idsvit is Complete and printed burly. The Departuantbss Pied
ties to y�n�°1g 60 aPPI�
of the affidavit for you to fill out in&c of vc��m reference number. In addAWM,an appScad
please be sure to ffi in the pamivticeme licatiam in tiny given year,need ody submit one affidavit indicating aurent
that must� muniple
(if U )ad a�"Job Site Address"the app&,..,b.0 write"an locations in (w or
PoNcy ibR ties been oflcially Buoyed of Iowa may be provided to dr0
marked by the city
town}"A cc of affidavit u fits fa 8mm l cn"of hcc+• A new a®dsvh Host t e food out each
MSCW ss proof�a valid affidavit a licmte a permit not related to any business or conm�acial venture
err.what a boos owner qj citima is obutming to kse this afidavk
(i.e.s dog license or l�a bona Iesva ese.)said pason is NOT regnirtd comp
The Ofia of Investipti°>v won>d bke m tbaole You in advance faf your cooperation and should you have any qo�
pkase do mtbesitsoe to give us s can.
The DeParuaent's address.telephone and t>Iz ttomba:
The Commonwealth of MamAchnsetta
Depugna t of Industrial Accidents
Of'lioe of InvetsdPdod
600 Washington Strut
Bo"MA02111
Tel. #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5.26-05 www.mass.gov/dia