Loading...
41 SABLE RD - BUILDING INSPECTION bl�loibOYYloC1 YM�►b� �� N Piopwdr bored In ;� reoa.n■soaaw.r Yok.NDY MU LDW PEIMIR APPLICATION FOR: Permit tort Dsok. ed. Pool, oie(Ck whWhWN WIY) Rool� Rsreot kwal K rC - m Sho PAPair6'trple0e. Odler' MJAU PILL OUR LEt LY a COMPLETELY TO AVOW MAU w PROCISSMIa TO THE INSPECTOR OF BUILDINGS: The undersigned haft apply for a Psm* to build SOWd% to 00 bNOwkp Owners Name ` LL K Address A Phone q( 5M c-,` �� _ (Of78, -) qL/ oB ( q Arddlsct's Name Address A Phone c Mederrire Nana /SA jq c �} Address s Phone �f�t-� S-r L781 1 3�� -7 y D© war�rr rx•v•on aaar� md"d arrwgr r a waft IN how wam trurwz.-�;---- wr kw"o. Iowa E led oor v� aW UJ • N A err. • �' 16 � e� Us. 11 x ��- SMAD MM THE MALTY OF PERJURY oEBCRIP I ION OF WORK TO U DONE oAmo,,j f c A 3. i u �+ f� (Jltvboa-) tt-JU L j)�� MAIL PERMIT TOE No. APPLICATION FOR PE l TO LOCA1T10N POUT GRANTED /0 tp OF 6UILDlK38 CITY OF SALEMO MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-748-9593 EXT. 3a0 MAYOR FAX: 978-740-9a46 Salem Buildin¢ 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. I The debris will be disposed of in: (Location of Facility) 5 '14T(0 A f f C Signature of Applicant 30 Date - Inc Lummuffpm .s ..� Department of Indwstrid Accidents or0' ew oflnwsdgations 600 Washington Street Boston,MA 02111 wwtdMemsowde Worker'Compensation insw=ce Affidavit: BWMers/ContradonMecbidan$Mumbers n u h►f P1M�Print Leeibht Name pp �b I-�J N �►-f��� 5-j 5u.��+ S«� Address: 7 City/StatelZ* Fism pbyes r Chsd<thr �box 'h w of Prof veipdrem. 4bYa with 4. [ I am a general oomractor and I 6 ❑New constiucdoa (M and/or pas6-tim4* have hived the 7. Remodeling le proprietor or P� imte6 an the attached sheet= B. � Demolition have m empbyua These sub-aonuacton haw ❑for me,in S. ❑ We w a romp• � 10. Electrical rya. ,No �0 oontp t ❑ or addidama offices have eaercisad their additions regoirod Iof memptiom Pa MGL 11.® Phtmbing repass 3.❑ I aID a bomeavner doing all work right e; 1S2,11(4),and wehrveno 12.0RoofrePaila insarana required]t� employees. ees. pq t ]odwe ME] Odd p, •/guy gq}iest to dtcb Ume#1 ant dw IM outay @eW=bd0w& w ft*err wI s ampI P"'qr t Elomeowwea wko M&Mk dt ttMdavtt imd dma�to�20 work tad sues NO 0OWh oom�on gut wkm0 P taw Affi&V t zScatina wed dm tCaotraAmatlo dwk ftis floc gut 0mbad o t MM=d abed ahowma d1A irrti of ar 06-canuldm ad 018k woltm,oaoP Per�+* mmm I am a ewplayw that b poddbW workers eampe maaloa lnumw9ja sty ealploysea ddow b dw pefly7 exd job slat I wx=ceCmManyiVame policy#or Self-in.Lic.# Expn don Data Job Site Addreu Crty/Staft0p. Attach a copy of the worhera',compeasodom pdky dedxmdom page(showhq the POlk7 number and eafirmtioi date). pafiumc m seewe w,aagt as rehired under Secdom 25A of MOL e. 152 can lead to tie imposition of crb3hw penalties of a fine up to f 1,500.00 and/or one-year miPriaommeot4 as well at civil peoWdo in the form of a STOP WORK ORDER and.fine of up b$250.00 a day against the viO121M. Be advised that a copy of this statement may be forwarded to dw MCC of Iavestigaoow of the DIA for Ww=ce wvwV verification. i As Aoriy eerf(. POW 4m pe"fAff°1psdkuy LW&g Ljf pwUd&bow b bns and eareat (017 ���•-�Z26 QBlrid gat mibK Do oaf wider IN tAb area 1s At eowpdrfd bl eL(p or Own a.0 Cky ar Totw: Permumeem N Issuiag Anthoriq(circle eae)t 1.Board of Health L Building Depart 3.City/Pow Clem 4 Eleetrled Inspector 3.Plaatbhsg Iaapedor 6.Odwr Coataet Tenon: Phose#: Massachusetts General Laws chapter 152 requires all employers m provide workers' compensation for rhea ernployeea Pursuant so this sto ute, an rasibym is defined u"...evay person m the service of anothr under any contract ofhisi, express or impli4 oral or written' An aapbyw is defined as"an b divA4 parmasb*anodatb4 corpmatm dr other legal entity,or any two or more of the foregoing etpmed is a joist emarprims,and inclaft the legal represestatives of a deceased employer,or the receiver Or, mstee of n.mdivAA pwmad*association or oda legal emuy,aapbYbg eII4byeas. lbwavess tha owner of a dwelling house having we men dan dtee sparnments and who resides thaeim,or the ocatpset of rho dwelling house of another who emplays patrons b do maintenance,construction or repair work os Inch dwelling be= or on the gotmds or budding appurtesam derem shall not because of such empbymcat be deemed m bean eatrployer." MGL chapter 15%{32SIX6)shoo agates that"ewery state or local kmbg apsey shall wkhboM the hawses or resewd of a Ikem or permit is operate a busses or to eoasprod bdMdtap Is the eommosweaMl for myapply ant who!as not predseed acceptable evidence of eompllasce with the insanee coverage required." Additionally,MGIL chaps 15$12XM stales"Neida de commanwcald not any of id polkW subdivisions shall enter into any contract for the pa6onmaoce ofpnblie work mutt acceptable evidence of ootopliasce wim the kworasoe regnireemennts of d&chapter have ban presented It eta centractmg sotbc®ty" Apptlants please fill out the workers'compensation affidavit ooampletely,by checkios the boxes that apply Is yaw situation and,if uaxasay,supply nab-ooa acbr(e)u me(sl addteae(es)and phone=nWs)along wph their catificaoe(s)of msursooe..Limited Liability Campania.OM or Limfted Liab>7ity Pumarships U.P)with to empbyces other than on manben or pmuatl, are not requited to carry workers'compemadn im num If an LLC err LLP does have employees,a policy is mpdnd Be advised du this affidavit maybe submitted to the Departmmtof Industrial Accidents for aon&sisdom of insurance coverage. Amo be ssra to dgasnd date the affidavit. 1be of Wt&%*should be returned to de city or Clown dot the application fbr the permit or Home is being requested,not the Department of Industrial Accidents. Should you have any quenions regarding the law or ifyou are required to obtain a workers' oonspeasation policy.please call the Deparhneot at the nnndter tinted below. Self-marred companies should ester their self insaana liceurensatber os die 119 -9 alo tiro Clq err Toners Off cisk Please be sure dot de affidavit is complete and printed legibly. Tfre Department has.provided a space at the bottom of the affdavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sate to fi11 in the pan it/liceme number which will be used as a reference number. In addition,an applicant that must submit multiple pamwbcense applications in any gives year,need only submit one afBdsvit indicating cm. policy Wbrmstion(If necessary)and under"Job site Address-the applicant should write"all loatbm a (city or town}"A copy of the dfid t guar has bees ofilcially stamped or ims kod by the city or town my be provided to the applicant as proof ibst a valid affidavit is on fib for f dire permits or licenses. Anew affidavit must be filed out each year.Where s home owrta or cidm is obtaining s license or permit m related to any bndness or commercial venture (ic a dog hocum or peimk to burs leaves M)said patron it NOT required is complete that affidavit The Office of Imvatigatiom would like to thank you in advance for your cooperation and should you has any gmdon% please do not hesittte b give m rcall. The Department's addttss,telephone and Its nsmba: The Commonwealth of Massachusetts Department of Industrial Accidents OfBm of Inveagsdtns 600 Washington street Be>stcta.MA 02111 TeL #617-7274900 east 4o6 or 1-a77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia