0017 PARADISE RD -BPA-08-119 HVAC STAPLES ' CITY UF SALEM
� '� � � PUBLIC PROPRERTY
" `'. DEPARTLIENT
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Construction Debris Disposal �1f�davit
(reyuircJ for all demulitiun a�u!rrnov:►tion work)
In �cwrJance wieh thz sixch adiuon of�he State Building Code, 730 CA1R soction i t 1.5
Debris, uid the provisiuns of viGL c 40,S 54;
Building Permit # _ , __ is issued with the conditioo that tht debris resultirtg from
this wurk shatl be disposed of in a properly licenszd waste disposai faciliry as dtfincd by v1GL c
l 11, S 1SOA.
The debris will be [r�nsported by:
_(�urt�� C-a�u���� ���"
u»me ot'hnatar)
fhe dcbris will be disposed uY in :
(uune oY facif�ty)
. ._— iadd�exs �tffuctl�lVJ � .
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' � � - CITY OF SALEM
PUBLIC PROPRERTY
��'"y DEPARTMENT
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81N11FR[F.Y UNIX:ULL
Yl.�vc�t lY Wn�tux�rorcSixtt'r�S�tF.w.Mnanuii.y i nG19T;2
'Ct1:97B.7aSri9S �F:�x:97f1-74C•Yx�6
Wbrkers' Compensadon Insursnce At7idsvit: Uuilders/Contractors/Electrlcfans/Plumbers
Applicant Informatioa Please Print Leeiblv
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V8(Tt6l�usiixcs/OrganizatioNlnJivufuull: C�l�SIA-L ail. �c�H�
Address: `J_'2 �C .o1»^f S-i',
City/StatciZip: ��,rJou2`t� ' h�K�. . Phonelt: `1& 1 - �I34-S�''7�
A�rr you an employer? Check the appropriute bos: '1'ypQ uf project(requfreJ):
I.U , ;un•r cmpluynr with� 4. Q I am u gcncrrl coultac�0�and[ g � �ew cautruction
ernpioyccs(full anJ/ur part-4me).' hava hired thc sub-cuntractors
2.� 1 am a sole pmpriemr or partncr- listtd oo rhe attached xhcet. � �• ❑ RemodelinQ
ship and have no employ�ti:x Theae sub-conaacwrs have 8. � Ikmoliaon
working tor me in xny cap�city. workers' wmp. insurnnce• 9. � Building addition
(Ko woiiccn'comp. inswanca 5. 0 We arc a coiporation und its
10.Q Elec[rical repairs or addidons
ruquircd) officers havc cxcrci.e�xl[he'u ,
3.0 1 am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing rcpairs or uclditiorm
inysell.[No workera cump. c. 152.§t(4).and we huvc no 12.� Ruof npairs
in�urance required.J t �mplayaex. [l�o wotkers' 13.v Jthrr d nos f�.U�L ,4�'TS
comp. iawrancc reyuind.]
•n��y�ppliauu qu�cM:cks bw lll mus�alno lill uw ihe vec�iun IwWw dwwiqp�A.tir wwk�s'cumpanv�iwi pulicy infurrte1iiun, �'
'I Wmw�wnm whu submil lhis aflldari�indin�in��hcy arc Joiny ul1 wo'Ic and�hrn Ain�wtyde cw��ncton mw�.uhm�a new a?Javi�in.lic�iny ri�A. '�..
�C.'unirx�urs ihu c6�ck fhis bm�muN ahxhad an a�Wi�iawJ.1�aAnwin�IIw name of tlq subtoNrae�on and�heir Wurken'oomp.puliry infwmaH�n. '�.
/um un rmployer thut Ls pruvldinX rvorkers'compansndon insamxee jor iuy einp/uyret Belory is the puliry and Job sile I�
injurinutiun. �-- — � � P_ S , eo � I
In.urance Company Vame: ���b CA c3� L � l 4� -
Policy q ur Self-ins. Lic.ri: �CW h .S ZS42S� ���,`1--__ Exp;ruiion Date: 'f � �'t' � B 7
J�b Sitc Adilrca5: �� ��IS Z � CityiState/Zip: ��',dL�M D✓L l'��
.\�rrch e copy of the �wrkers' compcm•rtlnn policy de�lrr•rtloq paKe(s6owinR the pollcy number�nd c:pirrtiva drte).
I�ailuro w x:curc coverage as requircd un�ler Section 25A uf�iGL c. 152 cau lead to the imposition ot criminal penulties of a
tlna up to SI,500.(�anJ/or one-year imprisomncnt, us wcll as civil �x:nalti�s in the form of a STUP WURK U2DER and 3 fine
oPup to 5250.00 a Jay againsl Ihe violator. 13e advircd thut a copy uf this slata:�ncnt�my be t'urwarJed to thc U17ict of
Im�c,ngauuns of ihe DIA for insurar.ce coverage v.riticalion.
/Ju hrrrby cr�lify u e�thr pr�� •und pr u ' rja rhu!1Le iafurinulion pruviJed ubuve ia«us auJ correct
� �
tii�•:cm�re: 1)�t � 1 �
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U�riu!use uuly. Du nnf wri�t i�+d�i.�ureu,m be ruaiv/ded by cily or rown oJJiriuL
City or 'fown: _ Pcrmitll.icense N
I+suing Aulhurily(circle oac): --- - _ -
1. IlnarJ uf 1(ralth 2. 13uildinL Dcpartmcnt ).Cit?•/lo���n Clerk a. Electrical Inspeetor 5. Plumbing Inspector 'I
G. Olher _ _ I
C�n�lacl Pcrsan: _- - . .. . .__ Phonc p: �I
Information and Instructions � � �
�4a�srchwetts General Lawt chapter I52 requins all cmployers to provide wo�kecs' coinpensation for cheir employees
Punu:�nt to chia��a[u�e.+n rmpfo�xa is defined as"...every person in the urvice uf anoiher under any contract oF hire.
expross ur impli..�d,oral or written."
.Vf eu�plo}�er is detined as"an individ�a�•Paca�CndiP�assoc+aa°°��°�P°���on or other legal entity,or any two or more
of�ho furtguinb mgaged in a joint entarprise,and irn:luding the legat repceseneatives of a 1ece:ued employet,or the
� [C�IYCf Of fI11.11CG U�Y11 tll(IIVI�YBI,p+umenhip.associatiun or o[hu Iaga1 catity.amploying tmployeea. Howcvcr ttu
ownet of a dwelting 6aue having not more tlian t6m aparm+enb and who resida therein.or�he occupant of ths
' dwclling 6ouu of anofier who employs persons to So mainc�nance,cunswcuon or repa'u work on iuch Jwelling houu
not bewuu of sucb em loyment be deemcd u�be an cmployer."
or on�he grounds or building appurtenant t6ercto s6all P
hiGL ch�ptcr 152,§25C(6)also staces chut"every state or tocal liceosin�agency shall wit6hold the issuan¢e or
renewal of a Ilccnu or permlt to operaN a busineas or to coostruct buildiap is t6e commouwealt6 for any
spplfcaat wbo has not prodaced�cceptabk evidence ot comptlaau with tAe Insurance covern�e required."�,"
a�Witionally, blGl.chapter 152,325C(7)states"Neither the commonweal�h nor azry of ib po
Iiticsl aubdiviaiom
h
anrer ineo any convact for che perfomrrnce uf public worlc mtil accepeable nvidence uf cumpliance w i�h the insuranee
requiramenv uf ehia chapter h3ve been prcsenccd to[he conerac[ing authoriry."
�PPUcanq
Please fill out the workera' compensaaon a�davit completety,by checr'vig the boxes that apply to your xi�uation and,if
necessary.wpplY sub-contractor(s)name(s),address(es)and phooe nwnber(s)along with their certificate(s)of
insurance. Limiced Liability Companies(LLC)or Limited Liabiliry Partnerships(LLP)with no amployees othcr than tha
membe+s or p:utnere,are not rcquired to carry workers'compensation insuranca If an LLC or LLP does have
Cmployees,u policy is required Be aeivixd that chis affidavit maY be submit[ed to the Departrnent of Indusaial
Acciden[s for confumation of insurance coverage. Also be sure ta sien aad date the rffidaviG Tlie atTidavit should
be retumod to the ciry or town that the applicadon for the pennit or license is being requzsted, not the Deparhtient of
Induscriul AcciJrn�. Should you have:u�y yucstiona tt�arding the law or if you:ue rCquirad co obtain a workers'
compensation policy,please call the Depamnent at[6e nwnber listcd below. Self-insured companies should enter their
.el(insurance�icrnse numbu on the appropriare line.
C(ty or Town OtBclab
Plcase 6c sure thae che affidavit is complete and printed Icgibly. The Department has provileJ u sp•rct ut thc bottom.
of cha affidrvit for you to fill out in the evrnt tttr OfHce of Investigations has to contact you regurding the applicant
PICeSC bC SUfC co till in�ha permiUlicense number which will be usad as a reference numbar. [n aSdition,an applicant
ihat mu+t aubmit multiple pennit/licenst applications in a¢y given yeaz,nead only submit one affiduvit indicacing curten[
policy information(if nncessary)and under'7ob Site Address"thz applicant should write"rll locaeiuns in (city ur
wwn)."A cupy of the affidnvit�hat has been officially s[ampeJ or muked by chb city or eown may be proviJed to ehe
applicunt as proof that a valid affi�vi[is on file for future permi[s or licensea. A new alTiduvit muxt 6e tilled out each
yaar. Whtn a home uwnet o�citizen is obraining a license or pmnit not relateJ to aay business or commercial ventwe
i i.a. :� dug lican.0 or permit to burn leaves etc.)said person ia VOT rcquired ro complzte this uffidavit.
�'hc pi ii�c of Invastigatiuns wouW like w thank you in�dvancm for yuuc cooperaeion •rnd shoulJ yuu h•rva uny questions,
plea�e Ju not htsica[e eo givc us u call.
The DepamntnPs address,celephone�nd fax number.
The Commonwealth of Massachusetts
Depactment of Industrial Accidents
O@lee of inveatl�at[oas
600 Washington Street
Boston, MA 021 l I
Tel. l� 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 11617-727-7749
a��„�� ;-?r�-os www.mass.gov/dia
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DEPARTII�F,�1TT
IJ.�FL�Y�.tSC1M,.
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130 Wwswtrc."7tw]�nEir��,n�`�y�,�op:s��ls 0/970
'Ifi 9?47ii959S�F,�te 97�.7�098�L
APPI.ICATION FOR THE REp,d►IR. RENOVATION CONSTRUCTION
DEMu�rivr. UR (.HANGE OF U�p OR �'*�ANCy FOR ANY EXISTING
STRUCTLTIL OR BUILpiNG
• 1.0 SITE INFORMATION � " . _
Locanon Nam.: i a.PI�S Coh i &,i�dinq;
_ __
Addres�- _ --- -
`�iluua-�6 S � -
�'Oi�h�� �a�ed�n a:Cansarvatlon Are�YM Hiaootic DIs61d YM
Z.0 OWNERSHIP INFORMATION "
4.1 Owno►d Land '
Nams:
Addreas:
Telephonr.
3.0 COMPLETE TH18 3ECTION FOR WORK IN E7IISIINp BUILDINGS ONLY
Addition ExiaGng �
Renovatlon Number of Stories Renovated �
Change in Use N�
Demalitlon ExisUng
Approximats yeac ot Area per floor (s� Renovated
constructlon or renovation
of exiating buildin9 New
8aet Description ot Proposed Work;
TZQ.�Lt4c�. �X i sT �!��/G U ,�-F c7"S Cv �`t'� �C-!�,�,
20� � '7""0/�S � � �' '�-'o� �k �T S
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ozss /
0� 4 — �aoG �
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What is ths curtent use ot ths Building4 9 �ny units?_,�.— � . .
l�,k��,.�� N dwellin ,1ww
Material of Bui�duW� Asbestos4
VYiU tM Buibitg Conform W l.aw?
t 1�C,
pvchitec�s lJam� 1 �� A ,� � '�oad _l ) n u� �,J,i�r v�+- b�Y}� 6 2.�7
P.ddress and�
Meehank's Nam�
����� ,�^��/� Sc�i� HIC Rs�istratfo��1
Constrtwiian S�D��s U�°nss M
Estlmated Ccs�a Proled=-�i�"�- PermU FN Calwlatla�
Permit Fe�if�'� Esmnatea c,oa x s��i�000 Resia«,w�
- - ---- - _ __ . E�Cost X i11IS1000 Gommerela�-- -
-- M Additfona� SS.00 is added as an
AdmtnistraWe c�-
�k�y�ro ihat all flelds ars proPsrN� �����t°avoW delays in Droce°sU9•
The undarsWnad does herebY aPPN�a Bufldin9 PermR fW to the ab stated\
speciflcaUons. Siyned under psnaHy of perlury /�
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