8 PHELPS ST - BUILDING INSPECTION (3) �J
Dateis
Mo�GlnYfol?Laceledh Yorl_Na� DE WIN of
is P "Nov Loomd in
awl OaaNIANG Awwd Yoh No
MINLOW PEIMMT APPLICATION POIM
Parinit t0:
(Chia whWhewr apply) R�iioof�l 1aY SidYq, CanNnpt Osok. Shad Pool.
PLEASE PILL OUT LEGIOLV A -� Y AVOID OELAYfi w PwOcwESwG
TO THE WSPECTOR OF BU LDING&
The undersigned hmW appals for a psm* to bold m c m fil, to the folw*V
speoftemm
OMwnre Name
Address a Photos 2 p$ S�' ( Q?m -)4,4 902 6
Atd*@Ws Name
Address -- !
mm
Address A Phons �� De (ewc>re C)r
a (:M ��3
00 Ir no PAP M of wi~ re rS
O�p�l
of 411dna? G-L{i P M a ' for how w Ay IMwaog?
VYO oodonw 10 low? _
VAIM a G 7CO2
6L) 10001 x
of A*MVV�
IMM UNDER THE PENALTY
OF PENURY
DESC wnc)N OF WOW TO K DONE
2YPn12PPme(�{ N U ), ICTI v CIA Llr.rr k lR4PQ-- rclr l-g
MAIL PEAWT T0: a
No. r7 dl�
APPLICATION FOR
/PERM/TO
won f S f s
000/'��o tC
LOCATION
PERK T GRANT'ED
MPECTM OF 8Uu DINf3S
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVIC2, 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:
(2M N(--( (Location of Facility)
Signature of Applicant
�zlw/0�
Date
�••\ Deportment of lnduarld Accidents
offlee olIjewsttgadons
600 Wasbinston Shad
Boston,MA 02111
tvtvwunossaot✓dpa
Worker'Compensation Inwrance A18davit: Bug&r$/Coutndon&ledricianilPlumben
A O Informati PUSH�t LetlffbhC
Name
Address:
Phow
Are you an employer!Cketlrr, w sPProPr[M box ZYPe d Projed"Quire m:
1.❑ I fret s employer with 4. 0 I am a Bengal contract and I 6. a
employees(kn and/or pum6noo Lave hued e a heft 7. otemwodUdillg
2.0 I am a sole pwpriew or Parma Bases ore�e a sb
ship sad Lave no empkrytes • Theta anb-oonrtacton have B. ❑ Demolition
vYorkw comp.bwaxwe. 9. 0> addition
Walking ins,� S. 0 We are a corporation sod its 10. Electrical repairs or addition•
mance
°�bwe c=ciead their
O or additions
ight
3.0 II a a Isomeowner doing an work r of exemption per MGL 11.0 PLmsbu+g repairs
Po c: 15Z¢1(41 and weLaveno 12.0 Roof repaint
v6tiji, comp.
insataoCt required l t awk"M i40 wodlese 13.0 Odw
comp.insurance mquued.l.
•�Y oPP dal chub box 01 mut do ea out ter naaon bdov drwiea tt k wetter'oonym+ttioa bPoHcr khcmgd MW dRdtvit mdicet na aeh
tHomeowmwho,obmdttbbdgdavitisdieotinatbmya�dawoknd&M him 09h: ao mramit,
TCarxadota Bye.dndt tbit box met�tuebad o dditiood drat drw�ma dr now of do sub-c �o:ott ad tok wo&W coup Po>iL7'mfontmiaa
I tide a ewpfiyw that isPvvi ft wurlees//'cwapsnsedos issurdwe for dry satpJoyu+ 3doty lS IAtPoNyl artJob�s
Ltsuiance CsampmyName:
policy#or Self-ire.Lie.* L 2 ? r(3s3 S /a b 1(o Expiration Date 2 2 3�a re
Job Site Address �iAdos U 1� City/Stat&2ip: alpn^ a
Attack a copy of the workaf,eompmaatlos Pesky declar"dos Page(akowisg tM Po"sumber and etplratiost draft)6
Failure to see cm emge as required under Section 25A of MGL c. 152 can lead to the ueposf m of c&aW Penalties of s
fine up to$1,500.00 and/or one-year ionp17150103WA as wed s"penalties in the fbM of a STOP WORK ORDER and a fine
of up to$250.W a day agaimt the violator. Be advised that a copy of this statement may be forwarded to the Office of
Live st4Woos of the DU for insurance covuags verification.
=Aphmby eel Pplsrl that tAae Wwm&*x pvW& d about Ar trw and eWr*M
2 ZG rJ5
3S
F
A* DVnest wrdte in ebb ens b be wap taUdAy dV A rAIMrt o,8ledals: Permweensef
hority(circle owls
Heakk L Building Department 3.Ckylrows Clerk 4.Electrical Inspector 5.Plumbing Inaped ter
Contact Penoss Phow tt:
Massachusetts General Laws chapter 152 requires all employers to provide worker' compensation for their employees.
Pursuant to this statute, an sw,p/aya is defined at"...every person in the service of another under any COMM of Lira,
express or implied.oral or written"
An anpAW is defined as"an indiV"pumas*aatociatioa,cOrpoiaaoa a other*legal casky,es any two or ntaeo
of the fonpoing engaged:in a joint entapsiI4 and including the I*d repraaestiva of a deceased employer,or the
receiver or tamtee cf erns n dividltal,pumasbip,associann or orbs legal edgy.employing employees. However the
owner of a dwelling house having not mesa than three apartments and who resides&aem,or the occupant of tine
dwelling bonse of another who en4lnys person ten do msmlenmoe,w=bucdm err npak wort a sacs der oubig borne
or on tie grounds orbuildng appurtenant thereb shad no:because of such empbytam be deemed to bean,employes.'
Mt L chapter 15%12SCs(6)also states that"every lose or local Yeeadag sped d M withhold the lsaaace or
renewal of a beeist or pern*to operate a busiaas or to construct bnfidh o In the commonwealth for sap
appacaat who but not produced aeeepbW evidence of compliance with the lsuuraaos coverage roqu hv&o.
Additionally,yam,chapter 152.123C(7)stiles"Neither me commonweal®mr say Of*poll"mb&iuwm d4d
emer into any contract to the paibnmance of public work and aocepmbIt evidence of compliance wig the insurance
requirements of dik chapter have beat presented to the counaetag satD ft.0
APP�
Please fill out the worker'compensation affidavit completely,by ehoCkiei the boxes that apply to your situation said,if
mayy,supply cob-oa (a)name(ij address(co)and phone mnoba(s)along win their catificate(s)of
mnaaaoe. Limited Liabft Compaeloi(LI.C)or Limited Liability Parmadups(LLP)with no empkryea other then the
members or parmen, ate not re.jai vd to arty worker'coition imaraoots. If an LLC or LLP docs Save
employees,a policy is ngaired. Be advised that this affidavit rosy be submitted to the Department of Indusaial
Accidents for confirmation of immance coverage. Also be sure to sign sad date the of ldwit. The affidavit should.
be retuned to the city or town that the application far tie permit or license is being regnated,act the Departraeut of
Industrial Accidents. Should you have any questions regarding the law or ifyou we required a obtain a workers'
con Pamtioe policy please can Depasanan at tle mmba Hued below. Self-insured companies should enter their
Self-insurance BMW number on the appmFiaee lien
Chy or Town O iidids
Please be sire that the affidavit is complete and printed legibly. The Department:has provided a space at the bottom
of the affidavit fer you to fill out in the even the Office of Investigations has to contact you regarding the appHcaot
Please be we to fill in the pernMeense number which will be used as a reference munber. In addition,an applicant
that must submit multiple pamitJ imm applications in my given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should waste"all locations in (city or
town}"A copy of the affidavit dWS but boa officially ammped or.madwd by the City at town may be provided b die
applfcaat as pmof that a valid affidavit is on dk far Aimee pamits or Sema A new affidavit most be Wed out each
year.Whore a home owner or doses is obtaining
en s Name or permit not related b any business or commercial vesture
(ice a dog hose or permit 1D buin leaves ere.)said person is NO complete dtiaT required to compl affidavit
The Office of Investigations would W to thank you in advance for your cooperation and should you have any questions.,
please do snot lesi!w'*Ske us a call.
The Department's address,telephone and fut member
The Commonwealth o€Messwhuselts
Dept WM of Industrial Accitieots
Ome of Inveatteatlom
600 Washington street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia