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22 PURITAN RD - BUILDING INSPECTION lyo Mo. loop ks wopahr Looaor In sown oro0loMas 1s Noprlp Comm a bOWANNNaIN O @L Lan PfIW APPLICATION PDlld pm"sm Ral00I. LW" OWL WW4 Pool. (CYala�Miiolwoiar apply) 2 n PImu PILL OLR Lawy A©OYPLrmy TO AMOiD omme w PrAmmews TO THE Rdf%CTOR OF BU LDNO& The widwsVW hsmW appin 1wt a ps mil to bWM aooWft 10 90 blwAkV A Roam Z Z pug Y Y-.5'�. ) AfGhbo 's Name Addrssa A Phone ( 1 Modyrdcs Now [eor��,v o s �'o n r 7-A;-&Ji g r Address A Phone -2 cr1q,4-T r) 4S 22 9 O watt t<sr p.00n w army ram'S i ,)g: 7 Moi "a Oo v s a*Awe sK hew allay 1MdM�4 0—.—�— wr mm"oars.10 kw? �- Baum aof!'Lo oo,, o0 m umm s W10. sss.uarw• D 6 Z Z3 y a �L�THE PENALTY OP P■NAMY oEBC M ION OF wont TO BE DONE MAIL PWM TO lJ7�f1�,L �Le � APPLICATION FOR PI MfITO LOCATION PERIAT GRANTED y INI�6�F Bl1q.DN�S CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEV J. USOVICX, 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: OUO 14�Si d`' (Location of Facili �✓H�, tY) S �SC.�7i�,-/ Signature of Applicant Date The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.govIl is Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly 'T Ilk Name (sus;pass/orginization/Individual) 4` q'¢ '' C9 �/ri/9 s C D,11 s rr✓L�/o Address: 7 X A 7-L Cr_a-L 6 City/State/Zip: ¢�c. o/9 h 9 " ` Phone#: q 'I ate- Are you an employer?Check the appropriate boa 5' " '' Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6., ❑ New'constmction ' employees(full and/or part-time).' have hired the sub:contractors 2.❑ I am a sole proprietor or partner- listed on the attached shect t ? Remodeling" ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity.. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5, VWe area corporation and its, 10.n Electrical repairs or additions required.] t officers have exercised their ' 3.❑ I am a homeowner doing all work right of exemption per MGI` 11.❑ Plumbing repairs or additions myself. [No workers' comp. a 152,§1(4),and we have no 12.❑ Roof.repairs insurance required.]t. employees:[No workers' 13.❑ Other 'comp.insurance required.] •Any applicant that checks box#1 must also fill outthe section below showing their workers'cornpensation policy infomummtioa t Homeowners who subunit this affidavit indicating they are doing all work and than Itin 6utside contractors must submit a new affidavit indicating such tConb actors that check this box must attached an additional sheet showing the nenx of the subconiractors and their workers'comp.policy information. I am an employer that is Providing workers compensation insurance for my employeex Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Faihre 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 imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 do hereby feZVI! r the nd penalties of perjury that the information provided above is true and correct Sipnaturc: Date: Phone#• L/S • 2 2-q o Official use only. Do not write in this area,to be completed by clty or town official, City or Town: PermitUceuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers.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 employer is defined as"an individual,partnership,association;corporation or other legal entity,or any two or more f of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the` owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of -- dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every, state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any 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-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited_Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC'or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also 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 beimg requested,not the Department of Industrial Accidents,. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the number listed below. Self-insured companies should enter their self-insurance license riu tuber on the appropriate lime. City or Town Officials Please be sure thatthe affidavit is complete and printed legibly. The Department bas 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 fill in the permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple pemrittlicense 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 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 new affidavit must be filled out each year.Where 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 021 It Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia