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34 PROCTOR ST - BUILDING INSPECTION APPLICATION FOR 1PEI W TO LOCATION 3v ��; � s ' PERMIT GRANTED 19 7t, Pvzx�' INSPECTOR OF BUILDMIGS 44AMIAMTOEfRAllik to APMveD f3Y TW JMSPZCMDB PWR TD A.PUW JSEINO GRANTkD CITY OF_SALEM / a wW In f., A. icmd"? Yu—No V lri]iiaa 49 4 oc7�`SJ Ati n ? YS No Permit to: SURDM PERMIT APPLICATION POW (Ckde whlohewr apply) Roof nstall Siding, Construct Deck, Shed, Pool, k/Replaa her. PLEASE FLL OUT LEGIBLY A COWILE LY TO AVOID DELAYS IN PROCESSIM TO THE INSPECTOR OF 13UILDINGS: +. The undwsoW her er by applin for a permit to build accord%to the.f Nowhg Owners / IF,vOf1 v32( uo�27/� Name : //,4WIV /14 /C�/ L/O Adkess a Phan. 0 Y_N�Si`�46 orz L /vt+4 Amhkods Name 61 v%7f 6/'p Address a Phone t Mechanics Name JCo Address a Phorw f What is Ve p mpo"ar tN 10W Arc1.w a twarq? M a tlMalYp,for row MWW asrw? VM kd&w°,�y n to low? AtetrMcfa? EMrrat.d oo1C 0,0 o pN LW • • 3 6-3 06 �j �� momue. x�aa�ae Xj� z/o6 ..J Lt t Sig lidin of Applicant STONED UNDER THE PENALTY' DESCiIrP'TION OF WORK TO BE DONE of PERJURY om '-� VD Moon- L1gNA011V y' :5b %S D-TiJ<f 1�0 S�Tv�O w95�5`E2 �O2y�✓� o>cf 3/2O MAIL PERMIT TO: �t j'(PQ. ueparrmenr of tnausma eectaents 00ce of Investigations 600 Washington Street Boston,MA 02111 wwwMassgowas Worker'Compensation Insurance Aii9davit: BuRders/Contractors/ElectridansMumbers AnDlicant Information Please Print Le¢ibly Name d �M�✓yi4 � t�/7_, Address: City/State/Zip: �D ✓�1'4 Phone#-- Are you an employer!Check the appropriate box* Type of proles(reitsired): 1.❑ I am a employer with 4. ❑ I am a Snag contractor and I employees(Sill and/or part time 0 bave hired dw sob-camractors 6. Q New rnnatrdctioa 2.❑ I am a sole proprietor or partner- listed on the attacked sbeet t 7. ❑ Remodeling sbip and have to employees These sub-contracans have 8. ❑ Demolition working for me in ��' instance, g. ❑ �8ad�on en•� s. ❑ We are a Corporation slid ils • 10.Q Electrical repairs or additions 3.❑ Ir bomeowner offioas have exercised their doing all work rigllt of exemption per MGL 11.0 Pk mbiog repairs or additions myself(No workers'gyp. a 152,11(41 and we have no 12.0 Roof repairs insurance ragnit ]t employes V40 wodreq' 13.Q Other comp.imntance required.] •Any appHwm dust theft boot#1 rota 40 fill out do section below daub wmkets'campeoudeo policy Wwwa0oec f Homeowners wbo ahroit min @M&vtt m6ce eg dwyae dome ON work and ran bm agode conmactms must anbmn it now afFideve rAwatina Such tCon necion not cheek du bone me aneehed an additional abort sbowioa me name of me sob-webacton and dm*wmkan•oweq.polity mfbrerrtim I am en employes tbet k pr*WA%S roorben'compemadou btsunneefor my employees Bdow 6 AW po&7 an/Job slat lxfwmalm Insurance Company Name: Policy#or Self im.Lic. # Expiration Date: Job Site Addrtaf: City/Stanv7jp: Attack a copy of the workers'compensation polity deelaradou page(allowing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year mtprisonulm as well as civil penalties in tie form of a STOP WORK ORDER and a fin of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I As busby es oala me PAW and ofperJury than the Inforaeadon provlded above a•as Corr*" D /J Phone# Qo?cid am omit. Do no twbe bs tAh arty to be completed by cliy or mw o leld City or Town: Permif/Weeme# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone# Massachusetts General Laws cbspur 152 requires all eoIPloyen to provide workers' wtr>pensadon'for their emptoyccL + is defined as"...very person in the service of anotber under my contract of Pursuant to this statute, an ewPfoya or implied,oral or Wince asftockdon,oorpa ermersbip, ation dr other legal entity,Of any two or coon An employe►is defined as"an individual,P and including tie kgsl a of a deceased en�loYer.or the of the fotegoing lea inajomt eaterptise, byes aatociadon or other legal emity,etrtployisg emp However the receiver or trustee of an mdivudtral.patnasbip, a�who maids therein,or the ooapant of the owner of a dwclting house having not coon than three aparamedt on such dwellim�boast dweiting boun of another who employs Persons p do maintenance,constrneaon or repay wort of on the grotmds erbutldint appurtenzat therdo shall not because of such omploymmtbe deemed to be an employer." MGL chapter 152,125C(6)*0 states that"every state or loa18eesdst aiMy star withiald the inuatee or renewal of a Ilcease orper"p to operate a business Or to construct btrildlnp In the commo wcski for MW Applicant wbo has sot produced aaept.W'Wen e Of to WUM with the inavaace eoverape ro4vre&" Additionally.MGL chapter 152,125C'(l)stasis"Neither the�oaweabb nor any of its political wbdivision• shall eery into any contract for the performance ofpublic work until acceptable evidence of compllaoce wig the insurance requiremean of thin chapter have been presented to the contracting auftft•» Apphcasb Please fill out the workers'omq..ti°n aflldavn cornpletely.by cheekier the boxes that apply So your situation and,if necaaaasy'anpplY sob-co °>ta)wme(sl addmss(es)and phone mmuber(s)along wick their Oldficate(a)of Pa msuratrca. Limited Liability Companies(lLQ or Limited Lisbtlity teershfps(l.LP)with no no4�other than tie ben or parmers,an not required to curt',worken' 00topensation i warasm If an LLC or LLP does have ernplo cM s policy is required. Be advised that this affidavit may be sobmined w the Department of Indosotial Accidents fix confirmation of insurance coverage. Also be sure to sign and daft the affidavit. The the should be returned to tie city or town that the application for the permit or license it being requested, Industrial A�idenls Should you have any quaff regarding*claw or if you are required to obtain a workers' compensation policy P> call the at the n a ber listed below. Self-insured compasn a slnnld enter the'¢ , self-iatiarance license mmzibes on 1&e 3PING1012M l City or Two Metals comp Please be sere that the affidavit t'o let 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 Inveatigetans has to contact you regarding tie applicant Please be sort to fill in the permit(ticeme amber wbich will be used as a reference m mber. In addition,an applicant that must submit multiple pemNlicense'pPlicatinoe in any given year,need only submit one affidavit indicating current policy WMnatron(if necessary)and under"Job Site Address"the applicant should write"all krcadons in (atY a town)"A onPy oftM affidavit that ban been of d lly stamped or msdwd by the dW or Iowa may be provided to the applicant at proof that a valid studs*is on file for&We permits or licemd. A new affidavit mnst be filled out each year.Where a home owner%citkm is obtaining a license or permit not related to any business or w mtenial ventan (le.a dog license or pc®t to burn leaves etc.)said person is NOT required to compkw this afBdsvit. the Office of Investigations would Hite to thank you in advance for your cooperation and should you have any questions. please do not hesitate to give us a o31 The Depamunt's address,ukpbone and fax comber: The Commonwealth of Massachusetts Department of 1ndu&W Accidents office of Inveodgationt 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 605 Revised 5-2 www.mass.gov/dta I �tiq�IT P��f� -1111F C. 01 OR A�c a�mmdfmptm9 t 'vOsts'lIi'IDW d4 FOP R 4l RsOd !P "'-P!iO'PH An dad v a![ �!D•4 axroxws io fq�taq�o oopw JPW io RW VML#oau WURmD ow mg!LopP PT anmbol h a 3 a""SqL �S Lt�'wappY -64 kvl)9�CA ter. �x eta (AnlvaI��uxa$sva�a) sp rya !s �d7o c di ASS �a L wPvR RION11; KUP aoval 'YWjS m q WK d4?mopP n lf4jM lP �fAa pewoag dfadad�ot�o pwod�p�9 tA��d�H�d4 P� oop 1�R1 I fM`R 0 PJDKj0 WmlAQd IV W.w 9mP R .UAYmddY Q -®Q i01YSQM(l vOA1111 wr oz=^oo T A71NvAs "".ML COLO) XVA Ott *AID MSG-"L(OLM -%IL OLs IO V1141a l s voovavc sinus MoAm"m cc 1N7wlvvdsp ALUBdOvd *nerd wj.Lxwnm*v*frW •NSEIVS AO Al12 -el � �-,SS S—�T� z i c �,�,ved Nr�NA��'M�uT, �y3 � 3 .� /2�2�� l a9� � i �� /�� _ � �3 �Ro Loo 2 APPROVED y m� Subject to appred a!17 any'othe authority ha ri>g,Suiaaiction.. CITY of 8 A t 2fa u. F!PX PREiEPION P K �V PI-A CARE OPROVED EiY EQR Ii:E6111rI.a�T�ti CE TYPE AND LOCADON OF ME Pylon ECT"'"1e !- 'CES• g .. ALL RRT PROTECTION DEVICES AR. 'OUej---CT iO A . [C IN"S.'i EST AN D INSPECTION,FOR COtAPLE"i E CCMCJ- ANCE WI T N THE FIRE CODE. �3�4TE1 Lit No oo KI I C 4eW 7$ h -r'j o 1110 t �� POOR- x ©u-v `_ 1�t,p2c5o r� i3�lJ�a nn how� 2X12� pr-3ix IZ Cca5 ;� �. c i r / h +7 y25-.017 z)�L El hI x `c�C �\w -I N �VmO� w DOZ N ,C o p ca n—L ?1CO-.4 OZI �3 c4 p(zo(f—j6 -5�11 2 NQ FL0o2 APPROVED Subject to approval.by any ottaer authority.bav .ju 'J,.eictioa. CITY of S. M.,F . FTT.EBY V :dEdJ" ^YT PLANZ EAPPRKWNIF LELY FOR N C L J 5I FE h D L,...... OF I— I wT,:Ge'= n3. ELI.. FiR*'PROTECTION. DEVICES !.°='Cli7JECl"i0 h L'.OVAL T-STAND INSPECTION,FOR COMPLETE CC k:911- ANGE VI TH THE FIRE CODE. nj 1RTH Li V! N9 2 oorn Ki I c l-��n1 7�x 7v8 O " (O� ' ,XIEctJ Pool,,, �wrJ �jt�jZvo►v� 1��0 �Oo rv1 1 2 X Z p 3 X I Z Cc-aS fie J-2 S,a -X L 61 W 40 n-L N&A Q hE