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7 PARADISE RD - BUILDING INSPECTION vuvwwAv*E fiL*p*ND O,PPROYEIi 8Y lm sae MWA IDA PAURf A M GRAMM CITY OF SALEM Is ftam y Lacmd in ioaatloo of Vw NiMoib OlMdol9 YM No—Z aai7/laa Is Pi"mty LooWed In ogneovo 0n Awa4 Yo4_No!� BU LOMilfii mmw APPNCATION MW Parma to: Ocis W*hwwr W*) Roof, Rowd. Install Siding, Corona Dsolc. Shed, Pool. Pisponvisom. o6w, O1C /JOfIF✓ ©O r°s PLEASE FILL OUT LE=LY A cowtaTEI.Y TO AYOID DELAYS W PROCESSING TO THE INSPECTOR OF BALDING&: The undarsiprwd hereby applies for a giant to build a000rdhg to Ow bkri q Owners Name 14;17 iC L: S/ Cl evy i"g' `/�i 14� Address & Phorw 7/ura�/� �Qo��( S'4�� (d1, e99- Tr-9 Z fthaeda Name Address& Phone L Meohre WB Name l�,,�v ��--es T Cos P Addrees A Phaw /% �r//� ,/, ��C , on �lyo -03 Nrr �7 V a fie pgmm m ouYatrp9 C rer ee /3 o;/er Q Do dig WINW d buYdlnp9 C oa c ',clle M a 'A g,br how awry bona"? wtr twaarq a� y�s A�toa4 /V� �/✓r0 0 qpr UWW it NJ o` 6a r Uo • X X� SVdb n of APPIi t 9W= UNDER THE PENALTY OSr PAY DESCRI nON OF WORK TO U DONE MAIL PERMIT TO: No. s gg- APPLICATION FOR' PER W TO ,.�/Pld3r- 41,4�66LayloAL 2,e LOCATION / PERMIT GRANTED APPOOVID MSPWM OF BUILDINGS The Commonwealth of Massaenwseris Department of Industrd Accidents offlM of lnwsdsadons 600 Washington Sdeet Boston,MA 02111 wtvta.massgott�ttTiir Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricimTlumbers pj..s&FrjdLeffibIji A plicant information Name � ��%•-�E/? v Co.''S 7' o . l� Address: /�! /C-V- //r- / City/StatrlZiP: s�/``• � Phase q`70 - 0 3 . er'L Chest the appropriate btm: Type of project(required): r[I emPlo9 4. ❑ I am a general contracoo and I 6. []New constitution a employer with— --. have hued the sub-conuackm s a�u(tA and � listed on the attached sheet t 7• ❑ Remodeling 1Leseeub-contraction have 8. ❑ Demolition and have in employee workers' comp. iosma� 9. ❑ Building additionrking forme in any capacity. S. We are a corporation and its or additional [No.worlcen' comp.romance of&m have exercised their I I.[] Ehxnical repairer rcgnued] right of exemption per MGL 11.E PhtmbMg repairs or addition 3.❑ 1 am a homeowner doing an work c 15 1 4 and we have no 12.[1 Roof repairs ( � o workers �• , CN �£ kryea. (No worktaa Offer t employees- 13.0 - inama>ta required.] comp.insurance required.]. ;Any epp*' w do cheeb box Ai Port goo 6n eta the nde n WO *0 sod* lute oWgdeoulgde' VMMMOUPort PosW Ms"MUM�m�'�idavit mdieMiaa each ?HOM,wnas.V.Vmewhoeetrmttidytrold itm�f�Y dot tCeotrectmo thrt cheek this box tuuR et0oehed m eddieond cheat ahowma the netts of floe sub-wet:reton and thdr wohete'comp.poltry mt'otTrmtten I eras ere eseployar the is pmUbrg workers'contpentadon bsunncafo►+Ky anMloYus Below is tke polky atrdJob atrr inf°ra"IMr"` Insurance Company Name: Expiration Date: Policy#or Self-im.Lie.#: / 7 �tir �/� S C l- City/StaWZip: b/ ,1 70 lob Site Address: number and expiration date). Attach a copy of the workers' compensation policy declarttttoa page(showing the pulley a of a Pa>>ure do secure coverage a required under Section 25A of MGL e. 152 can lead to the imposition of criminal peaalti fine up to$I,500.00 and/or one-yew iraprisomam.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator• Be advised that a copy of this statement maybe farvvarded to the Office of Imestigatiom of the DIA for i 111130 a coverage vmticarim 1 do hereby cardJj un/ar floe pabrs sad peaabias of p&*q that dm Grfwmadoa provllad above It Ow sal cemaet D / Z z o� - o G Q eld uts antic Do Na writer IN tbb area,to be coayplated 0 e1q'orMm o,89cld City or Town: Permweesse N issuing Authority(circle one): 1.Board of Heakh 2.Building Department 3.Ckyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Phone S: Contact Person: 1i11V1 analaa.iVnl Nl1La inl0ia aaa.a,lVauo Massachusetts General Laws chapter 152 requires all employers m provide workers' compensation for their employees: Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,wsocisuoq,omporation or other legal entity.or any two or more of the foregoing engaged in a joint euterprise,sail including the legal representatives of a deceased employer,or the receiver or.trustee of an individual,partnaft association or other legal eutity,employing employees. However the owner of a dwelling house having rot non than three apartments and who resides therein,or the occapaot of the dwelling house of another who employs persons to do maintenance,construction or repair wort on such dwelling home or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe." MGL chapter 152,¢25C(6)also stun that"every state or local Ileendng ageaey shall wkbkM the bnsaaee or renewal of a license or permit to operate a budsest or to construct buildings in the coum nsweakh for my apptleut who has net produced acceptable evideaee of compliance wkh the inara see covengpr requhv&- Additionally,MGL chapter 152,125C(7)states"Neither diecoamwnweahh nor my of its political subdivisions shall enter into any contract for the Pefourance ofpublic wodt until acceptable evidence of compliance with the insurance requirements of this chapter bave been presented to the ooinactisg suftrity." Applicub Please fill out the workers'compensation affidavit completely,by checking the boxes that apply so yaw situation and,if necessary,supply anb-contrucan(s)name(sl address(a)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partoershipa(LLP)with no employees other than the members or partners,are not required to carry workers'compensation iuurance, 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 insuranoe coverage. Ala be am to sip and date the affldsvk. The affidavit should be returned to the city or town that the application for the permit or license is being requ atoll,not the Department of Industrial Accidents.. Should you have any questions regarding the law or if you we required to obtain a workers' compensation policy,please call fire Department at the number listed below. Self-insured winpanies should enter their self-insurance license nnmba on the appropriate line. City or Town Officials Please be slue that the affidavit is complete and printed legibly. The Department bas.provided a space at the bottom of the affidavit for you to fill out in the went d►e Office of Investigations has to contact you regarding the applicant Please be sate to fill in the pamidtieeme number which will be used as a reference number. In addition,an applicant that must submit multiple permiMiccuae appticatiou m 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,marinrd by the.city of town may be provided to the applicant as proof that a valid affidavit is on file for firpue permits or liceom A new affidavit nun be frilled out each yea.When a home owner or citizen is obtaining a license or permit not related'10 any business or commercial venture (it a dog license or permit to barn leaves etc.)said person is NOT required to complete this affidavit The Office of investigations would blue to thank you in advance for your cooperation and should you have any questions, please do not hesitste to"give as aeall. The Departuncurs address,telephone and in number The Commonwealth of Massachusetts Dgmrtatent of Industrial Accidents Office of Investigattong 600 Washington street Bosttm,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-2ti-OS www.mm.gov/dia CITY OF SALEMv MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASH I NGTON STREET, 3R0 FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, 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: DC-1 (Location of Facility) Sa ^^ et Signature of Applicant D e