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23 PROCTOR ST - BUILDING INSPECTION (2) l��is use aurant of the Su*ft? Material at rist d t3u�drq? f ` � M it dwelki&how many unNs? � sb �s VW the tttA&V ConImm to LWO Asbestos? Amhftcs Name Aduile= Addraw and Phone17 Medwdea Name Ge i�ck Addrea and Plwne Ca+eYudfon SupenLmn t.�nae• ��4'7/3 HIC Registration d Esttrndsd Cost Perna Fee 2 ai " Permit Fee Eadmatad Cost X$71:1000 ResfdantW EsOnebd Coat X=11J:100g C mwddl An AddWmW :6.00 is added as an AdmMW6eWe diarge. Wm sure that an news are propery arw mg"vrrittan to avoid delays In Proc@Bsft The wderslpned do"herby apply for a Bum Permit to to above stated xe, L= specramooru. Sigrwd under penally of Psl+ry Date - r s :A -4� F y EI' roiT-SXLEn PUBLIC PROPERLY DEPARTMENT )7� wrn 130wAsaiawsnm•S#AjjKwASAcH Wm6jYN tti Ma+s.ssss•r,W sn74a"s A<*PLCATI IN FOR T= RFIA B2-W-U m coff '�'�t?CTim DILMDU TION.OR CAA Z Ot USZ OR OCC[nH FQR ANY s'acra'r NG- ORMULaNG . 1.0 SfTt INFORMATION - loowllsn Namwe coc Bt+Ydk+a � . .. . . -- �� lLY1fv2 S� �-• � , i Propsry Y bowled In w;Coiwwallm Any"Y HltlOrb OIMMot Y c 2.6 OMEROW INFORMATION it Owaw of Land h NwW =Pti address: 03 TNaphorw ? 30 COMPLETE THIS SECTION FOR WORK IN EYMM BUILDINGS ONLY AddWon Exlstlrq Rerwvatlon Numbs of Stork" Renovated Charw in Use New Demolition Approximate yaw of Area per floor(sf) Renovated construction or renovation of exis" building New add Description of Proposed Work: --- - -- Mail Permit Im CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT wIMM"""aIF.Y naLitaxl At vroa 12C Hlaswct:YavSralnR o Satinet,W.%gL%Cln.serrs0197:: AL:97L743-9595 •FAX:97p740.9946 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrictans/PMmbers .applicant Information Please Print Legibly Name tNusinesatOtysrrinatiavlttdivtdtmp: A& �/E.,4�G{,� Addrm: �L— /�� City/State/Zip: 1� 1�� `� 1'hoaa 0: Are YPfi an empteysr7 Cheek the appropriate bore ryp.ofprojeet(regained): 1.MI um a crrrpbyer with 4. ❑ 1 am a genre!contractor and I 6. ❑New construction empluytros(full and/or part-time).• have hired the sub-comractors 2.Q 1 am a sole proprietor or partner- listed on the attached sheet t 7. (j Remodeling ship and have no employuos Thar wbaonaaetors have V. Cl Demolition wanting for Inc in any capacity. workers'comp. insurance. q. ❑ �addition INN workers'comp, insurance 3. Q We am a corporation and its 10. Electrical required.) officers have exerciacd thew ❑ repairs or additions 3.Q I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,91(4),and we have no 12.0 Ruof repairs insurance required.) t employees.INN workers' 13.Q Other comp. inwran c required.] Aiq:,ppliraal the chocks box al roan nine all"a.wii.w twtw asowias'bair Work='eumppWlbn peehol io6umluios I t. Wollfa sub Wooled this a"Idatru ine4uina trey alp&bW nett work and net,kit,eWtWe eon soon en u submit a raw arfuls irWiaaina w.b. :C.tntnlalns that diuck the beer nut anaehd an W011etnl Am Jmwiry Me time of dW ad tbea workers'canes.policy neferltexhos. l am on employer that b providing worker'compemaden hismranee for my tmplayees, Below is the polity and/ob slit iufurmadoa p Insurance Company Name: _ CG U2U /11�V•2Aa-✓fl �j�y�� Policy 4 or Self-ins. Lie. 0: Ont 704�r— //nn y(��j Fxpirrlion Date: 7 p 7 Job Site Address: ©a �U City/StatuZ)p: �LU Attach a copy of oho workers'compensation policy declaration page(showing the policy number and espiratiuo.date) : Failure to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a fine up to S I.560.00;and/or one-year impristmrncnt,as well as civil penalties in the form of a STOP WORK ORDER and s fine 'If up to $250.00 a day adainst flit violator. Ile advised that a wpy of this statement may be wrwarded to the Of ice of Ini'c,ng,untls of Lhc DIA for insurance euvengc verification. /do hereby certify milder the pains and pe,nu/des of per/ary that the/nfo►meNon provided above it tine and correct Pht rave 4- Off/dal cost only, no eat wdit is fhb of to be eamp/ded by eity or fovea o/J/rimL City or 'row": __ Pe rmit/Llccnseti___" _. . Issuing Authority (circle one): I. livard of 1Ivaltit 2. 8uildin9 Ile:part file 11t 3. Cis/fovea Clerk 4. Electrical Iifspecfor 5. Plumbing Inspector 6. Other C atuct Person: _ Phone N: , i information and instructions Massachusetts General Laws chapter 1 32 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an etwpfoyte is defined as .every person in the service of another under,any contract of him empress or implied.oral or writttm." An eaopleyor n deBaed as"m individual,permership,stentati i�corporation«other kgal cnthY'or any two or mere of the foregoing engaged in a joint emerprioo,and including the legal representatives of a deceased employer.or the association or other legal entity.employing employees However the receiver a dwcllo of ao it bavinsl,of.onepartnership-a ' and who resides therein.OF the ooeuPa0 of the owner of a dwelling house having net mote than throe mainapartenance. dwelling{house of another who employs persons to do maintesaaca.construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall trot because of such employment be deemed to be an employer." �tGL chapter t 52.4�(6)�o states that"every gas"or legal licensing St -—i s tbt withhold cs tsswaeo or renewal of a Ileesse or permit to operate a business or to construct bttildlagsL the'eommosweolth far trey appicant who bee am produce aeeWable evidence o Of coPUSIM"with the Instr ed"oad coverage requir Additionally.MGL chapter 152.42SC(7)states"Neither the commonwealth not any of ite political suith di s shell d enter into espy contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely.by checking the boxes that apply to your situation and if necessary.supply sub.cormactor(s)nams(s),addreas(cs)and phone nambar(s)along with their certificatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employers other than the members or partners,ate not required to carry workers'compensation insurance. if an LLC or LLP does have employe",a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidence for confirmation of insurance coverage' AUG be sure to sign and date the affidavit Tile affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Depatuncu of Ieulustriul Accidents. Should you have any questions regarding the low or if you are required to obtain a workers' compensation policy.Please Call the Department at tha number listed below. Self-insured companies should enter their ,elf.insurance license number on the IMISMISfillft line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be Sure to till in the pemtiglicense number which will be used as a reference number. In addition,an applicant that must submit multiple Pc applications a 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 is (city Car town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be tilled out each year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to brim leaves etc.)said person is NOT required to complete this affidavit I'he Otiice of Alvestigatiuns would like to thank you in advance for your cooperation and should you have any questions. please du not hesitate to give us•a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Deptlitonent of Industrial Accidents OAkt of Invertlptlew 600 Washington Sheet Boston,MA 02111 Tel. #617-727 4900 eat 406 or 1-877-MASSAFE Fax N 617-727-7749 �e�i.cd i-26-05 www.amn.gov/dia CITY of SALEm PUBLIC PROPRERTY DEPARTMENT �,Vfit all ,m- •IL ?l�u• t 7.te1NC:Jiis1ER iuiln. VIKiwVAAbur tttr:t0�1ad✓19q�fttt:9�eJ�6seN Construedon Debris Disposst Affidavit (mtuimd for an detrreutim aad rarovatien work) (a=onlaneo w ith the sixtls edition of dw Stw 8uildim Code.7SO CNil smtdoa 1 t 1.S Debris.and dw provisions o(rtGL a 40.S S* SWIJis{Permit f - _ is issued with the condidos due the debris rcwA&S dom this wok shall be disposed of in a propady licensed waste disposal fbeility as dellned by vl(R.e 1l1.SIs" The debris will be transported by: tastes ot'ttaatM rho&--bris will be disposed of in : (team of rull,ty)- . ..art {