5 ROPES ST - BUILDING INSPECTION (3) fIaNSMUSTIDEf D APPROVED BY THE
1dSPF.CI'L1B PlWR TD A.P.E all f T MING GRANTED
CITY OF_SALEM
Dab
Is PmWty Uoplod in / rooatum of QQ
rNFWIOfbDUlrla? YM Now aai]diaa �� /,OPeS�
is Rap"Loomw In
ft Gw m mWn AM? Yak_No
BWLDWG PERMIT APPLICATION FOR:
Pwmd to:
(Circle "dwver apply) Root, Reroof, IrulWl Corwow Shad, Pool.
RspaiNFteplaa.
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSM
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a pom►d to build according to the following
speodiicalkm.
Owner's Name ( 1A1, O JZ�LI14a y15
Address & Phone j
Architect's Name
Address & Phone ( )
Maaranics Name �i�✓� C� )Z
Address & Phone s�L,� �2G��,may✓ j�?�) Z O G 2 9/
WRw Is ria prpm m b~
MAWMd a b~ 0 1 a dwobq,for raw many lamwrr?
WE b wft canna/m to we S MbMaa? WO
Eftnow com d city rnr r N A Stall lJooMa r
XSignature cf Applicant
SwillO UNDER THE PENALTY
OF PMUIRY
OF WORK TO BE DONE
G
I i ,
f11(D,1PCr U� .
MAIL PERMIT TO: 7—
i
No.
APPLICATION FOR
PERM R TO
(�/NYG .S9(�/ ✓6 � �Crc ��.f2
LOCATION
PERMIT-GRANTED 1
�ev/enbec � 7.d OS /
VFD
OR OF43FJILDINGS =
5
r f
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleplease
a pit Leber
Fibjy
Applicant Information
Name (g /Organizatiowindividual):
Address:
�
City/StateJZip: ./ Phone#:
Are you as employer?Check the appropriate box: r7, C]
project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I ew construction
employees(fall and/or part-time).* have hired the sub-contractorsemodeling
listed on the attached sleet t2.�I am a sole proprietor or partner- These sub contractors have emolition
ship and have no employees workers' comp. insurance. . uckling addition
working for me in any capacity. 5 ❑ We an a corporation and its
[No workers' comp. insurance 10.❑ Electrical repairs or additions
officers have exercised their
retlaired.] 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance requfrod]t employees. [No workers' 13.0 Other
comp.insurance required].
Any applicant ttffi checb box#1 must also fill out the section below showing their worker'ompensation Policy mfimrrtoa' -
1 uck
Honswwaets wtso submit this amgdavlt indicatutg they we doing all work and then hire outside eonbactors must aubnrit a new affidavit n ass
tCoatrec0otq that check this lox most attached an additional sheet showing the none of the mb cootractor and their wodcer'comp.polity
information. =200025
Islas an employer thou is providing workers'compensation Insurance for my employees. Below it the po/tey and fob site
Info►"Jon.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/StatdZip:
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 certify u r the pe of pedwy that the information provided abgrw h#w and correct
D ,` D
S•
Pbow#:
OQ7e/al use only. Do nar write in this area,to be completed by city or town otifeJal
City or Town: Permittucense#
Issuing Authority(drde one):
1.Board of Health 2.Building Department 3.Cftyfrowo Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
1111V1 illMbiVu fill�► 111061 krf.lVll►7
Massachusetts General Laws chapter 151 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
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased ernployer,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 the
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-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(I.LP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or UP 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 being 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 mrmber on the appropriate lime.
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 fill in the pernidiicense number which will be used as a reference number. In addition,an applicant
that most submit multiple permitflicense 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 most 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 burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like 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 numbs:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 4o6 or 1-877-WSSAFE
Fax#617-727-7749
Revised 5-26 OS www mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
arm I* PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978.745-9595 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 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:
//1--'/ (Location of Facility) (LAe
Signature of App icant
D e L/