9 SALTONSTALL PKWY - BUILDING INSPECTION fD APPROVED BY T414E
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BVILI WA PERMIT APPLIrATION FOR.
Permit to:
(Circle wtdo mw apply) Roof. Reroof. Install Sidkrg. Construct DsoK Shed, Pool,
RepaiNReplace. Other:
PLEASE FILL Otrr LEOWLY&COMPLETELY TO AVOID DELAYS W PROCESSM
TO THE INSPECTOR OF BUILDINGS:
The underaigned hereby applies for a permit to build according to the following
specificationt
Owrteer's Nacre ef�4f� �f - .4-1 O// �s—
Aftrown A Phi .Sff< any 5 i/-// SC
Arohkeds Name
Address & Phone j )
Mechanics Name
Address & Phone I 1
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ao.s lxirrovs t
t't`. /1 Signature of Applicant
WMD UNDER THE PENALTY
OF PWUURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: 9 S,9/, i oy s
NO.
APPLICATION FOR
PERMR TO
LOCATION
PERMIT GRANTED
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APF90VFD
ECTOR OF WLDINGS
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Ii a CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3Ro FLOOR
SALEM. MASSACHUSETTS 01970
TELEPHONE: 978-749-9599 FXT. 380
STANLEY J. USOVICZ, JR• FAX: 978-740-9546
MAYOR
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'. HOMEOWNER LICENSE EXEMPTION
i
Please prirrt.
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Job Location
Home Owner Address
Home Owner Telephone
I, Present Mailing Address
The current exemption of"Homeowners"was extended to include��gQ for
dwellings of two Units or less and to role that theow such wn«is as supervisor.
hire who does not possess a license,p
DEFINITION OF HOMEOWNER resides or intends to reside,on
Persons)who owns a parcel of land on which he/she attached or detached
which them is,or is intended to be,a one or two family dwelling,
structures accessory to such use and/or farm structures• �►Person who constructs more
than one home in a two year period shall not be considered a homeowner.cial, on a form abl to the Building
1'hotrteownet''shall submit t responsible f allsuch work performed under the Building
Official, that he/she be respo
Permit.
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
homeowner'certifies that he/she understands the City of Salem
The undersigned `
Building Department minimum inspection procedures and requirements and that he/she
y will comply with said procedures and OV'M requirements.
' HOMEOWNERS SIGNATURE �=-----'"
APPROVAL OF BUILDING INSPECTOR
i
See other side for state code
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dle
Workers' Compensation Insurance Affidavit: Butiders/Contractors/Electricians/Plumbers
Please Print Le 'bl
A licant Information �U 6 ���
Name ( yprtlon/lndtvtdttal): L W C E
q � � C�cc — (fir rK
Address: 5 O2e�lS�
City/State/Zip: rn /i) 01 y70 Phone#: 7`//
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and I 6. ❑New construction
1.❑ I employer with �._• have hired the sub-contractors
empp loyees(NU and/or part-finer). 7. F1 Remodeling
listed on the attached sheet t
2.❑ I am a sole proprietor or Palmer- These sub-contractors have $• ❑ Demolition
ship and have on employees workers' comp. insurance g. Buulldmg addition
wonting for i>x in any capacity. 5. ❑ We are a corporation add its
=(No workrs' comp.insurance 10.❑ Electrical repairs or additions
Ie officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
Tight of exemption per MGL
myself. [No workers' cor1P. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 1319
comp. insurance required.].
'AaY applicmt stet checb box Nl inert also fill out the section below showing exit workers'cornpensatim Policy mfomtetioa
;Any
who eutattit this affidavit indicating they ate dome all work and then tiro outside contractors must wsbmit a new effidevh indicating Such
tConMwwm ft+at check this box muss attached an*Mtionel Sheet showing the come of the sob-contractors and their workers'comp.PdlicY infoTrmetioa•
I am an employer that it providing workers'compensadon insurance for my emp
loy
ee
s Below Lt the policy and Job sift'
infenneuw.
Insurance Company Name:
✓ (3 0 �i � `) 3 0O Expiration Date:
Policy#or Self-nos.Lin#: (__----_
��tU.�g�,�,� �'�-�/MACityiStatV2ip:
Job Site Address: �/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 anprisoument,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 tertJfy audit the pales and penaMks of perjury that the informadon Pmvided above Is Prue and correct
S
Phone#
oofeld use onlyt Do no write in this area,to be comp/eJed by shy of Mon OhIC I
City or Town: PermWUeense t➢
Issuing Authority(circle one):
1.Bond of fieakh 2.Building Department 3.Ckyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
1111V1 lilNbiVll NiIK 111061 kva.iV110
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." M
6 .
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 employer,or the
receiver or.trustec 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 insuranee coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neider 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,(II.Q or Limited Liability Partnerships(LLP)with no employees other than tine
numbers 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 sore 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 number 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 permidlicense number which will be used as a reference mmmber. In addition, an applicant
that must submit multiple permit'licenseapplications 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 lure 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 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2t;-os www ma gov/dia
0
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. LISOVICZ, 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:
� �� I ► f (Location of Facility)
Signature of Applicant
1
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Date