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CITY OF SALEM,, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USovICZ, JR. TELEPHONE: 978.745-9593 EXT. 380
MAYOR FAX: 978-740.9846
Salem Buildine Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of our
BuildingPermit is Y
that the debris res
ulting
tin from this w
of m a properly licensed solid waste disposalwork shall be disposed
facility
ty as defined b M
Chapter III, S 150 A. Y GL
The debris will be disposed of in:
(Location of Facility)
gnature of Applicant
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' 1 J �f Please Print Legibly
Name (Businesss/Organization/Individual): pe °`lI q1 W 1✓-t � %
Address: `7 S Fovi d;
City/State/Zip: t/&4-tlt Phone #: 97� 26S-'�L55
Are you an employer? Check the appropriate box: Type of project(required):
1.X I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (fill]and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 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. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 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#I must also fill out the section below showing their workers'compensation policy information
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors most submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. L� c_4�d
Insurance Company Name: 7Tat- In&u► aAce_ 6>!!!ea[ y
Policy#or Self-ins. Lic. #: 0 w 13611—S 7q2, Expiration Date:
Job Site Address: 62 tv-Rr '"`'. City/State/Zip: E� (CaA
Attach a copy of the workers' compensation policy declaration page(showing 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 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 com u e ar and penalties of perjury that the information provided above is true and correct
Si a Date: �106
Phone 265- -'2 2 55
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6, Other
Contact Person: Phone#:
- .` 3�� ✓/GC V/dlYLpid/2UM¢L/./L d�v'`7.(/6fRC1N/4�N�
BOARD OF BUILDING REGULATIONS-
- License: CONSTRUCTION SUPERVISOR
Number: CS 089839
f Birthdate: 06119/1972
'+ Expires: 06/19/2008 Tr.no: 89839
Restricted: 00
SCOTT P HOUSE. -
854 RROADWAY#1 ,4
HAVERHILL, MA 01832
Commissioner
,�. ✓�ze V/dGt)RLOJ#/M[L�CIt C�.. l�R.k32f/eaiP,�d
_ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 129774
Expiration: 11/212007
Type: DBA
PELLA WINDOWS AND DOORS
SCOTT HOUSE
45 FONDI RD. j,L.....,—�� f�'✓
HAVERHILL,MA 01832 Administrator
NO HER-- - - DRIVER'S LICENSE '
S69694966
DATE OF BIRTH CLASS REST HEIGHT 5EX 6
06-19-1972 D 6-00 M r
EXPIRES
06-19-2006
HOUSE y
SCOTT P
854 BROADWAY
APT qI °aIaiBlf
HAVERHILL,MA •�.
01832 „p
r
Pella Corporation
Designer Series`"'
CR� French Sliding Door
Vent• Low—E IG
National Fenestration I
Argon Filled • Clear Panel
Rating Council®
ENERGY PERFORMANCE RATINGS
U-Factor (U.SJI-P) Solar Heat Gain Coefficient
0.30 0.24
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0.40 - -
Manufacturer stipulates Mat Mese ratings conform to epDllceble NFRC procedures for determining
whole product performance.NFRC ratings are tletennlned for a tixetl set of environmental conditions
and a specific product size.NFRC does net recommend any products and does not wanant the
suitability of any product for any specific use.For mare Infornacon.ce11(641)621-3114 or visit
Pella's web site at www.pellaxorn ar visit NFRC's web site at www.nfrc.og
St
' 1 WINDOW AND DOOR '
MANUFACTURERS ASSOCIATION
SGO-R70 71x82
CONFORMS TO ANSI/AAMAJNWWDA 10111.6.2.97
70
Complies with HUD UM 111 (3rd Party)