42-44 PARK ST - BUILDING INSPECTION 1
• CIS �
FACM GRANTED
CITY OF_SALEM
DAN
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11111.11111.0" PERMIT APPLICATION FOR:
Permit a:
(Circa whichewr apply) Roof Rmd Inala Sidk%p CarntlW D" Shed, Pool,
RepaidRep" Odwr:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF SULDINGS:
The wxWsgrwd hereby applies br a pormit to build aocw tp to 00 bl wmV
specilicawm
OWWS Name A4A10 n iN� �FAZc�g7Jr�
Address APhone
A chiteces Name
Address a Phone j I
Mechanics Name ,
Address& Phone j l
veri is sr vWPo••a txrlar�p� 1t�s��jc?q L
mm"of twrldkp9 II a WON.Ior how monr Leman?
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F.Mimwd coot l ,� CIW umm• N P` 81ne Llouw•
one 0XlorrawU,.t Lie. ftuhn of Applicant
SW= CINDER THE PENALTY
OF PWUURY
DESCRIPTION OF WORK TO BE DONE
MA1L PERMIT T0:
2oj WAstiler! 25�
j°
APPLICATION FOR
PERMT TO
t
LOCATION
PERMIT.GRANTED
APPROVED
94SPECTM OF BIALDINM
f
The Commonwtdth ofMassoeausefts
Department of Industrid Accidents
Office of Inwsbaadon.*
600 Washington Shod
Boston,MA 02111
tvtvintnassgov/dla
Workers' Compensation Insurance Affidavit: Bugders/Contractots/EIecM ami/Plumbers
Please PrhA1&ZM
Apal-i—cant Inf rm 111011 20
Name
� yanizatiadlndlvimtsl): hi2)OS �L �1N F�ZG�R71r e
Ate, /),` S I)OW L,
City/State/Ztp:
A'4vd)l I'^fl of 5 6J � Phone
er!Check the
proper box: r7.
Pe at proied(required):
r2.
you u employ 4. 0 I am a general convactof and I New constnwtiva
I am a employer with • have hued the sub oontraclma ,�u(
empbyees(&B and/or part tune). listed on the attached sheet t Rentodeting
1 am a sole proprietor of paemer- These sub-contcaclon have S. ❑ Demolition
sbip and have no emploYM wow. e0mp• insaT mM 9. ❑ Ba&ft addition
working forme in arty��' We are a tion and its
(No workers' comp•insurance 5' officers their
Electrical Tepaies or additions
le4u ]
tt81u r�of exemption per MGL 11•0 Phtmbing ' or additions
3.( I am a homeowner doing an work
my8etf [No workers, COMP. c: 152,11(4),and we have no 12.0 Roof repair
insurance rcgaued]t empioyea. [No workers' 13.0 Other
comp.insutance requbvd.].
'Any eP'P>�6a thin ebedet box#1 rim !90 fill out fe owdoo w 0 and am oubide omi
SM '' "Ve`m o ' a6rmt �ffid�vit mmeaLma such
YHomeo=AbeA*nwlidsdfidevn fty d on
tCem,,,ins dw dkak fibbox nmet Oneelwd m edditaooel abed ebowag as um a of the eub•conhedae end 9Kir wotken'cco4•PoiwY IDfotmettoo.
I site&a esrployer tAst b'p►ovldbrd trorkers'conWxsadoa Wursme jor my employees. Below is&polry and job star
btformdb" Name:
Inaurance company
policy#or Self-ins.Lie.#:
Expitation Date:
City/Staw7Ap:
Job Site Address: oa date}
Attach a copy of the workers' compensation policy declaration page(showing the policy aamber sad esptratl
m to gecaTe coverage a4 required under Section 25A of MGL c. 152 can lead to the imposition of Criminal Penalties of a
ga as well as civil penalties in the form of a STOP WORK ORDER and a fine
fine up to$1,500.01)aad/of one year ssnprisomnsna.
of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Imestigatistiom of the DIA for inanraoce Coverage verification.
I defhmby ten*aeries rAs psbu osJ oft&lnfWmadon provbbrd&bow is freeue and correctDaft•�
QM wale fop 1W wr&in tA&sma,M be eellVkA d by e/V or ARM offlt/A
City or Town: Permbutease#
Issuing Authority(circle one):
1.Board of Health 2.Bunding Department 3.Clty/I owes Clerk 4 Ehxtrieai Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
11i1Vi iiiaaaiVii Nile iliAai aa%.a.JLVii13
Massachusetts General Laws chapter 152 requires all employes to 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 mployer is defined as"an individual,pumash*assoeiatioz,corporation err other legal entity,or any two or mere
of the foregoing engaged in a joint auterprite,and including the legal representatives of a deceased employer,or the
receives or trustee of an individual,pumas*association of other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who residea therein,or the ooarpaot of the
dwelling house of another who eVkryS persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or bmldi g appurtenant Sheet shall not because of such employment be deemed to be an errgsloyer."
MGL chapter 152,125C(6)also state that"every date or local licensing agency span wlthhdd the bsmanee or
renewal of a Ilene or permit to operate a badness or to construct buildings in the commonweaMh for any
apptleut who has ant produced acceptable evidence of compliance with the iaswanee coverage required."
Additionally,MGL chapter 152,125C(7)states"Neither die commonwealth nor army of its political subdivisions Shan
enter into any contract for the performance of public work until acceptable evidence of compliance with the insnrasoe
requirements of this chApser have been presented so the contracting authority."
Applicants
Please fin out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-coishiactr(s)name(s),ad&c*es)and phone number(s)along with dim catificate(a)of
insurance. Limited Liability Cmapasiea(LLC)or Limited Liability Partnerships 11.LP)with no empl yces other than the
members or partners, are not required to carry workers'compensation issursum If an LLC,or LLP does have
employees,a policy is requhV& Be advised that this affidavit may be submitted to the Department of Indaaiiial
Accidents for confirmation of issuance coveage. Alan be sure to sign and date the affidavit. The affidavit should_
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you bare any questions regarding site law or if you are required to obtain a workers'
compensation policy,Please call the Department at the member listed below. Self-ins red companies should entu they
self--insurance ficemenumber on the appropriate fine.
Clty or Town Off cimb
Please be sure thd the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fbr you to fill out in the event die Office of investigations has to contact you regarding the applicant
Please be sore to fill in the permit/license number which will be used as a reference number. in addition,an applicant
that mud submit multiple porniMicense 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 locations in (city or
town}"A copy of the affidavit that her been oflkWIY stamped or,marked by the city_or town may be provided to to
applicant as proof that a valid affidavit is on file for f6mre permits of licenses. A new affidavit area be fulled out each
year where a home owner or citizen a obtaining a home or perntit not related to any business or commercial venim
(ia a dog license or permit to bun leaves etc.)said person is NOT required to compkm this affidavit
The Office of Investigations would hire to thank you in advance for your cooperation and should you have any questions,
please do not hesitat0b give us scan.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigatlons
600 Washington Sliest
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26 OS www.mm.gov/dia
CITY OF SALEM9 MASSACHUSETTS
* PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3R0 FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, 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) LP ,f)/Ar AA
Signature of Applicant
0
Date