18 ROCKDALE - BUILDING INSPECTION 4
No.�"V CJ Odd Y—OS
M PMMtj LOOM Yl
"NMwbM~ Yam_No 2"Um a
;r OWWWWWRAwd Ya .Nof�
BURMO NOW APPUUTION FM
Pamlit t0:
Ada"*** M apply) Road, ft COrdVW Daok. Md P"
PAPSWftOWOL.
PLEASE F LL OUT LMKY a COYPI.ETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BU LDING&
The uwdarsipnad haft apply for a permit to bUMd aocwft to # a bbwkp
OIMWINama roePJTr
Adrass rf Phone /d -2 Y/-may/Z
Afd*@WsNam. p_(,=,&V Ar'lll/'
AddMM& Phone . 41 .. f w &// .Si
Madames NOW CJ 1Z-1 '/v
A*Wwm A Phone 3�- % j97fi 77Y - ors f
"m is Is PAP" b1ltlYip9 (4y/L,Y L S '47//241
MOM d blldnp9 r a dwaa'q.br how mmp I�s4
MIN b11YlYfp oorrollll b Url1 A' sh~ fTJo
E ud oor /D7>, CW Uo r N A sma ua •
y -
W42wo of Appkmt
SIfi = LMM THE MALTY
OF MAW
DESCWWN OF MIM TO BE DONE
MAIL PERMIT TO: /S l 14y 1)e vvelu/6- or9��
I
3 '
i
APPLICATION FOR
PIMIII TO
LOCATION
PEFUNT GRANTED
7
INSP OF BUILDMK3S
ST BE ATTACHED BEFORE PERMIT CAN
per 100 square It gross area,minimum$15.00
r'
Deparnment opndustrid Accident
Orce of Investigations
600 Waskinrom Stoat
Boston,MA 02111
wwttktnassgod!!i
Worker'Compensation Insurance Affidavit: Bufiders Contndors/Eledridans/Plnmben
Ago—kagi Warm MAN Plies Print Leghk
Name A/Lot//mLew 4� -
Address: sl C�n�e�u f S✓ e/�•vv M-L
City/StatelLip+ //�•v,/P�r /�1�- Phane 97jP
rol
u mpbyes?Ched<tie appropriate boa: Type otpro]ect(required):
a employer.with 4. [] I am a general comraaor and I 6 0 New cononction
bym(fa anNor par"24� have hood e a lwh sub-ao BUM t 7. 0 Remodeling
a sole proprietor or per- listed -attacLod slat
There wb-oontraaon Len S. ❑ Demolition
ship andbove to employees .comp.%mamma 9 ❑ Budding addition,
WOMBS for me in any capadw. add iM
(No�gq,CD*f oe S. of ate a corporation 10.0 Electrical repair or additions;
ofHoe+a Lave esereieed theft or additions
3. I a homoowu1.doh all woskk rW of eaemptiao per MGL 11.0 Plumbing repairs
[No waskeo• 0: 152,11(41 and we have so 12.0 Roof Npaaa
insoraoa regttiied]t . emPlo [No[ o waheW 13.® O&w C/V �L
comp.insurance squired].
'AsY ePv> tbet cberb Ume sl m�t.Lo SH err*A MWOs below Aeov+isa weir wvkms' POtM,Y�OtmeaOc
tItcmoo ma..ibO.oumn9lf..eae vii;e�&gmdfteawstkenderrsimecub*c suwdVAUNPsewZM&Vit g=A
temustw.drtebeokdhatwam+s"Amea.amriosd.tree•boomsebenmrormewbeossselusodflrkwoetse'- t�bitionrWim
mm
Ae A eaepto)atAsr b provldLrg wsrbrs'comp xmdon k wmwOfor nY eneployen idol;b AU ps/k)sndjob A*
hovanceConwayName Gi1q�• '� %fjT e
Policy#or Self-ins.Lic.# /��/ Expiration Data.
Job Site Addras I,P - °C��'�� City/Statet: S'P-/Pn,
Attack a Copy of tie workwe,compa adon polky dedardlon page(shaving the polky number tied apiradoa date)6
Faikim d sccwc anvaage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up w$1,500.00 xWof one-yar as wen as der penalties in the form of a STOP WORK ORDER and a fine
of up to$250.W a day against the violator. Be advised that a copy of dds statement may be forw x"to floe Office of
Investigations of the DIA for iosataoa aovaage verlflaalim
I do heieiy cord*under dtep+bn Ad penshln pn/ 7 thatthe bfwxwdm pmWdmd&bars Js brie amid ewrnt
'5 '76 - 7 C, S
ojk d rite W* at eec wvtte As&&s/ri,ap br eVAVjdd by e/V alAtsrn odJ"
City or Town: Pesumeease fI
Issuing Authority(drde one):
1.Board of Health L Budding Department 3.Ckyfrown Clerk 4.Electrical Ingwdor S.Plumbing Inspector
6.Odwr
Contact Person: Phone#:
Massachmem General Laws chapter 152 requires ail employers to provide worka ' compensation for their employcia
Pursuant m this statute, an esybyee is defined at"...every person in the service of another under entry contract ofLi%,
.—«.—etepress orimP .teed.ural err.wnt6ea." .. '►...
An employer is defined as"an bdividaa>,pumas*aaoaado4 gorpotstioa err other legal entity,of pry two of more
of the foregoing e2110941 is a Joins cmcrpris4 and.mehtding the legal represco adm of a deceased employer,or the
receiver air.tsmtee of as it dividml.parmeszbq,assoaaticia or other ko emy employing ampbyea. However the
owner of a dwelling house having not rose than Om apartments and who resides&ae*of the oeoatpaet of the
dwelling home of another who emp"peraom b do maintenance,comanction at iq)*work one stick dwelling home
at an the grounds orbaift cap a mm thank shall not became of such a mpbymeat be deemed to be an ea toy r"
MGL chapter 15412SC(6)aka states that"every state or local Revising agency der/wkbkaM the Ngatiee or
renewal d a Mcataa or permit to operate a badness ar to eonand buddhip in the commeiawedft for sap
appReaat who Ito be produced se ceptable e:vldesce of comoss e t with the lnaaranoe coverage required"
AdditimaDY.MM chapter JS2.4ZXM suw"Neidw the aommonweaft ter say of ill PON"wbdivisiou shall
eater into gay ewnnaa fbr the pertmance ofpubUc war*mind acceptable evidence of eompliazz with the ioattaaoe
requirements of tbii-chapta ban been presented to the contracting sudie ty."
Applicants
Please fin out at worker'compensation affidavit completely,by cheeft the boxes that apply to yew situation mod,if
necessary,supply tub•cojitm ci( )name ft a ldress(es)and phone mnober(s)akmg wi&their cati&ate(s)of
ice.Limited Liabft Companies(LLC)or Limited Lid t7ity Puma d*W)with no aopbyets'otha dum the
members or pumas,are not regaimd Io cury workaa'compessad n fmmana. If an LLC or LLP doesave h
employees,a policy b required. Be advised that this affidavit maybe submitted to the Department of Iaduairw
Accidents for confirmation of insurance coverage. Abu be sure to sign and date the sfrldsvL The affidavit should
be wauned tu the city or town drat site application fhr the permit or Nee=is being requested,ant the Deparnneat of
idw"rW Accideu. Should you have any gaatiom regarding the law or ifyou are required to obtain a workesn'
compensation policy,please can the Deputmest at the number Bated below Self-insured oompamia should eater their
setf-iasaanoa&ensenmaber cn toe atptoopriree line
City or Two OffidaM
Please be we that the affidavit is complete and printed legibly. The Department has.pwvided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations bas to contact you regarding ng the applicaut
Please be sure to fiR in the perRdOkeme nornI which will be used a a rdaeece number. In addition,an applicant
that matt submit multiple parniNicense applications a any given yea,need only submit one affidavit indicating M.
Policy inf mn*a(If necasary)and under"Job Site Address"the applicant shades write"all bcatiom in_(city or
town}"A copy ofth affidavit that has been officieft stamped or,matked by the,city or town my be provided to 6e
applicant a proof that a valid affidavit is as fib Air&atie permits or Hcensea. new affidavit most be filled our each
year.Whoa is bona awnar of citizen is ob>ammg a licaue or permit not related to my bashim or com mucial venture
(ie.a dog licesao or permit to bola leaves ere.)said person it NOT required W complete this affidavit
The Office of investigations would hue to thank you in advance for your cooperation and should you have any quatioat..
please do not hesitate Id Sive m a cWL
The Depumreat's address,telephone and finer camber
'Ike Commonweal&of Massadiusetq
Department of Indtubial Accidettts
Office of Invetldgadlne
600 Washington Street
Bost,MA 021 It
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-OS www.mm.gov/dia
w-
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, 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:
SU e Q&al,,•&y (Location of Facility) S:�t/e,-A
Signature of Applicant
Date
9a ) oe) l h�r