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19 PATTON RD - BUILDING INSPECTION CITY of SALEM PUBLIC PROPRERTY DEPARTMENT x�rar uc vrs...+anoKsnsr.sa esK ht�sstlwa.�iisOt9v0 rei 9yL7eiyS% .Rax:OM440-Sy Workers' Cotspensuton Insurance Af8ftvir &IllderWCQR"Wtan/Eleetrldulu/Phas re a o Name tlkveesftOrtrti:,,;e,vtnJrvwh.11: y ,, G�- Atidreanr_ /2 4/ti�l 1,, 14 City/StMWziW._Sb&-t-L, iiiYlra . I'eooelw_ �-5��- �32- SS�C� Arr yes an eapMyvt Cheek the approprttua bets i.01 w a employs with ♦. ❑ ►sm a gernnd eostraerer rued 1 Type of: (rMslradk empluyem(full an for pur"me).• have hired the sub.cuMractors 6' Mrap eoetwettetiae 2. I am a sole proprietor or partmr- listed am dw attached sheet t 7. a Remodeling Ship and have no employees These haw s ❑Demolition working for me in any capacity. workare'camp insanujoe• q, ❑gins oddities (Ae workers'comp insurance S. ❑ We an a Corporation an!its 'eq�J officers have curcmed their 10.Q Electrical repairs or addition 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.(No*otters'comp, e. 132a¢1(a).and we haw no 12.0 Roof mpsirs 'nsrtrserce trquirrd J► employeee.No workers' comp. insurance mquirwLJ M[3 Odwr Aso+pphead or ehadr tee el msm oho as ore raw rn os t•dor dewiti keir rate•aryewtiN Pwfw3 ioaoardot►'tluowwn wto.ub"nth amddiv i heka4a dry arc dairy rt wok one'^ Am tlw amY/e eaarramaa anw kdlaaiea rai. .ahorh a aao am kvir('.,masers dw clank Wee hmt mar attached Am adadmd ahem`t• ^/tar nee der akceoeaeron mid 4ait*color' Ws•P-Policy 06mudea /mnr ua ernpfeyer that b prev/dIa{workers'eowprawdoa huaraaee/a ray edp/oyeea Be/ow/r rke paBa2.'!!rVjr. Inxsrnrtee Company Vomr. rn G -{�. -.1 Policy e or Salr•-ins.Lied.M !� �/G (� / 7 C� Eapinuron Date: _Dkc 3 6 Jub Site AdJresa: / ! L City/st:atazip: t-f &4 .utaeb it Copy of the worksts'compensatlum policy deeldratloa page(sbowing the policy number and espiradom date). Ifai lure w wcum coverage as required under Se:tion 23A us•-IGL a. 152 can lead to the imposition of criminal penalties of a tinu up as 50.00a day yor4sui one-year imprisonment,as well as Civil Ponalliaa in the form ofa STOP WORK ORDER and a run -if up w i250.00 a Jay�tptiaat tlw Via imprisonment,lie advised that a cupy urthis statement may be forwarded eo the Opice of 1,1v:sngauorrs m1'dta DIA for insurance sxsveragsr verification. /Jo hereby re under the poias mild nu/t/rs u/pri/ary rker the in oraw ke / proru/td ebow is true no cornet i i..n:n,r•" -L� Date• /l �� 8 F en//r 40 ea f wrfp/a rh/r orrAa to br eoarpfetdby chyof town OA-U n burity (circle one):Ilrulth t. IluiWing Ikpartment 1.City/fosse Clerk 4. Electrical luspactor S. Plumbing Inspector son: Phone p: Information and Instructions �tassachuaems General Laws chapter 152 requires all employers to provide workers' Canpenauim for their nmtpbyesa PI,» •pt to m General as s chapte is defined as"..Avery parson is the service of another under any convent of hits. thi auds e.press of unpliod.and or writers" two a to" s dtllted r era iodivtdttal.paaew+M►+er°01'o°a'00�01'O0e err other heal eoutY. any .AA s of � ,a a jotat sasaepnss.gad itehtnt6t{tl�tegal reptsaeerariva of a dt ceased employer.�ot� of the foregtwla Per &soswa ioa ar other►bpi eatiga.employing employes Mceiver or terms of ya tndtvidnnl.pattnarshie speratsma and who rettidss dtor"err the oavPa+of dr owner of a dw*Nft boors hewing not rots thaw thew Maintenance.cuosvuctism or tepok work on such dwelling house Parsnof to be rn employer." who emPleYa dnvrd _. ,Iwe�rtg hours of aaothar �,�ae.g oat beasuss a[soh employment be appurtenant or on the grounds or building htGL ck►par 152.{2SCi6)SW,toes than-W4117 state W bed gnttsfag apaey shd knees"or renewed of a peeve or lt+^�to operate a badness w a Causer"balldlego In the eevsaws+coveragew roquisoC. awes wbe bee test pndaa/.«.Ptald'evidence compose"ea a`"�st Poutieet subdivisions dud .Uditiowdly.,slat draper 152.i2SQ7►oscsstates-Wsi workdtar until a evidence of comoiswA with the imursam ever`1°tO any f lbw c far have�presented the com raeuag atrhod*- ,egn;natena ofthis chapter ApPftma nt our situation and,if Please gill not the workers' ctmtpsnsaoea afildavit �• Checking the boxes that apply Y Of atscoor(s)narre(s).addrom(es)and phase sumbar(a)along with their employ e(s) the neKeassey,supply Companies(LLC)or Limited Liability Pasuwf iP ILLP)with no employees other than ,nsuranos. LW&W -bilit art y ro entry w��.Compensation insurance. if an LLC or LLP does have members or ptl¢marb uiesd. r advised that this affildavit any be submitted to the Department of industrial erlploytxs,•policy of wurance � & '�be sun er sip and date the attidevft. 71ne afl<Idavit should Accidents for confirmation that the appticadea for the permis err license is being requested.not the Department of he resumed o the city or even the law or if you are required so obtain a worker• compensation Accidents. Should�l the any y�tt soother l�below. Self-bmmd eompan�s should ester their COmpateiLWa pllinsen••'e •^•r^�-- self-insurstta liearin number on the City ere Town Oat dab r,._�._._-.,..� . .. -. tsd lei The Department has provided a ap►cs at thr.hotto4 pease he sure that the affidnvtt is complete and theo f Investigations the apPlkw§L of the affidavit for you to fill out init eem evnuml,er whi howill be used as are ence numbers[addition,an Wficzar 121vase be sun o lilt in the po submit one affidavit indicating current that must submit multiple permit/license applications A any given y applicant ear, should write"all locations in__(city or policy information lit necessary)and under"Job Site Address oar marked by ry licenses. A now _ town A eopY of rhs sffidavit that has been officially stamped sub nits city or tows may be providod to the it applicant as proof that a valid affidavit is oar fib for gintturo perm not related o any business raw be renew year. Where a hams owner or cidzcn is obtaining a license or pea mit Incense or to burn leaves ea.)said person is NOT required to complete this affidsviL t i.e.ti dog � tK� l'hc Ofti:c of Investigations would like to thank you in advance for your cooperation and should you have any questions, picric du not hesitate to give us a call. The Departtment's address,telephone and fax number: The COmmottataltlt of Masaachtlsetts Deputmaat of Iadasttial Atxideats ofiWe of G►wadptNag 600 Washio0too Stoat Boston,MA 02111 Tel. Al 617-7274900=11406 or 1-977-MASSAFE Fax 0 617-727-7749 ;tcviscd 5-'_6-1i5 www.mam.gov/dia ! CITY OF SALEM PUBLIC PROPRERTY DEPAR'TM- ENT r.�:�rrur• �a...�f► �L�u• l'1."1.�LV::JNS 7daT UAkU.WOLIt w lkalla::r .. Construction Debris Disposst Affidavit (requital fbr all daeaGtion and rammadon worst) In aeconlanm with the six&edition of the State Sus dift Coda;730 CAIR sot tion It 1.3 Debris,and the provisions o(MCL a 40,3 54 euildin{Fwmk d _ _ is iswted widt the eotadtdom rust the debris creaking Amu this wort dull be disposod of in a property licensed waste dlsportol facility as dented by.%(GL e 1It.Sis" The debris will be ( et nad.d rho&--bris wilt be disposed of in Marne uY far�tdy) .�.M:r'sya of Cyr a.ly) a' ••ifd S OF P P ROPERTY FARTMFr�iT .�„�. t3evw�ow�w ssmr.s�uav�ocs�mrsu»�e a:erea+saaa•re:e�a�.e•w APPLICATION FOR THZ REPAIR. ULaQyA33 _ COWS U4 rrnnr_ DEAOLYTIM OR CIIANG2 OP U3Z OR =ZANCY FOR ANY ZXraMG STRUCT[lAi; OR SIM DIM �.�m INFORMATION . I.oca*m Nsmee SQL t g Is boated In s;C menvalm Anne YM Wd*ft DISH YM 9A OWNt'sRZiiHIP INFORMATION 2.1 Owner e1 Land _ Names L✓L 2 cum S Addreae: ` � j� • t �`D TMepltorwx LOCOMPUM THIS SECTION 06R WORK IN EntaLNp BUILONos ONLY Addition Edging Renovatlon Number of Stories [:RwwwaW Change in Use OemoUtlon Existing Approximate year of Area per floor(at) FNew enovated constructlon or renovation 200 of existing building add Description of Proposed Work: jjW£J 4 n., `Pc�It l N (J S�� I� 1� S' 1 / T J�c9 'C zF --- -- ---Mail Permit to; /-7 ,a LC 41 - r� What is tha OW"t use of the guildkp? Msts"of su&*V?--= t{dWO01%how msny uNb9 W M the&AdM ConIwM b tseR Asbasfos? Arohilsds Naar Address wd Phony madw,we Nano canabudbn Suparvisas Likoerw HIC RapMtatlon/ ©� g D Fs J� Es1lmMsd Coat of Projad i�.,/ Pwas Fes 902do n--�-- Es*nstsd Cost X i71111000 Residential Esenslad Cost X iti/111000 Camaunia�--—An Addltlmut si.0o is added as an _. . AdmMra.dve A --9-. Make sun that all fields an properly and Ipitdlr written to avoid delays In PooaNng. Tha undersigned does herby apply fbr a flu*" Permit to build to the tt�7rs tad spina, Sigrrd under pensMY of perJurYR�—f Date i J Z9 a 7