3 SCENIC WAY - BUILDING INSPECTION (4) k PIGMIV Looabd h 'A"tioe of
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SIMLDSitI PEIMYT APPUICATWN FM
Pannit t0:
(C cb v***wm apply) Roof. Raroof. Ifl" Wft CardO t Dook. Shad. P"
ftpuDmpbm o1w.
PLEASE PILL OUT LEOIYLY A COMPLETELY TO AVOID DELAYS I"PROCEffSWti
TO THE IWSPECTOR OF SUILDINOS:
The hrft apPW fw a pwmk to buM aomft to tha foYowkp
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Lie. / Of Appimt -
U*M UN THE PENALTY
DESCRIPFWN OF WOVA TO BE DONE oP PwunY
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Department ojlndus&W Accidents
O,Q9ce of inwsdsa&xs
600 Washington Sld+td
Boston,MA 02111
wwWmemsodlV
Worker'Compensation Insaaranee AMSv[t: Binder:IContnctora/Elecdicians/Plambers
P!' P
ADIDUCAPI Inf
Name
Aftesa:
City/State/vp: I �vcoc mm 01,760
Are you as tmPW T Cbmk thtapptopriate boas Type dProled(Mdre m:
1.® I ims a empbya with a 9OW9 mntrs�and I 6 ❑New 4. ❑ Ism .
stn and/or parl4im l* Lave bired the a■b woaatsoracmVioym 7 0 Remoa�
2 ❑ I a® p of per- Haw on the am bed deft=
These anb-oontraaon Lave S. ❑ Demolition
ship and bxve no emploYea workete comp.imutanea 9. ❑ Btnft addition.
v for me in S. ❑ We are a cmporatias and is ❑ or additions
[No w o*as'comp oflicas bave au ciaed their 10. Ehxlrical repairs
right of exemption pet MGL or additions
3.❑ II�n a�Lomeae'nes doing an work 11.❑ PLtmbinfi gabs
�. wmp c: 152,11(4�and we nave l0 12.0 Roof repairs
Wma cee mquked•J t omployem. No wo&cW 13.0 Otba
comp.b=rA=nTdM&l
'Any.pp"I do cbeeb box a1 mat�Lo 6D uut>b reAlan babes am ltas' aatgda• oomtmoon mmtmint a 6mi< davit m i
t tbunoowm do icb iobMs bo affidavtt dod a a do son of do mob-mntmolm nod�woeme amp po"
:Cawtrnetart�td cheek tldr bane must atteehad o additional rbaet show'm f .. .
Wonnsfim
1 car as enpttaya ew is p oWilb d werkarol eomap mado■l■sw■■etjs►cry en:pinycm ddow w tArtpo"and job sft
hraranceCamPsnYN�:ne: /�
Policy#or Self-im.Lic. Exp nd=Data ice_
3 S;6,1;C City/StatdZip:
Job Site adarea.
declaration page(sbofg ore ply•umber and esplratloa date}
Attach a copy of the workers'eompando■policy
Faftc Inseen covaage as fcyuized m da Section 25A of MGL C. 152 can lead IDthe imposition of anal penalties of a
fine up to S15oo.00 and/or one-year iaiQriso�.as wen as dd paultia in the form of a STOP WORK ORDER and a fim
of up to$250.00 a day apiwt the violanr. Be advised that a COPY of tbis sbtemwt msy be forwarded tD the Office of
brvesdpdm of the DIA for inmmce Oovaage verifio m
I do iie sliycon*aa/�nw&ePaw and peenaMar ef.Pv AN Ad bf"&'Ionpro►IJt/J ebo►v b Apse and erred
OjkAd rLtt W* Dv nd wrdtr 4s oils ana,to be comph d bjpOr Or or *I*"
City or Towns Permmee■se fi
Iasuing Adhorky(drek OW):
1.Board of Health 2-Building Departmeat 3.City/Tows Clerk 4.EkcUI al Inspeetw S-Plumbing Inspector
6.Other
Phone
Contact Pawn: #:
Massachusetts General Laws chapter 152 require all employers m provide wodkas' compensation far their employe& �
Pursuant to this stamte, an ewplgw is defined n"...evay person in the service of another undo any contract of Lim,
express or implied,and or WrktcL"_
An anpisjw is defined as"an individoat Pxuad p,aEfOpaiIOa,cmpotalim dr other legal cmity,or any two or morn
of the foregoing engaged in a joint entapcife,and iocludiog the legal nVam Wves of a deceased euiployer,or the
receive or.trmteo of m indiyidtid,parmaship,asodation or other legal effigy,employing employees. Hovrever tb
owns of a dwdl ing house 6sviog tut mite than three aparnmems and who resides thaeio,or the ocapaet of the
dwelling bme of mother who employs penom a do mamtemooe,eomtrtrcooe or apair wosk an sub dwelling bonne
or on the grounds a building appurtemat 6erM shall we because of sash employment be deemed to be an employer."
MGL chapter 152,12SC(d)also stases that"ever►state ar local Yeteft agnq dud wkbbld the Maaaoe or
renewal of a ncene err pwmB to operate a badness or to construct bWkMW in the eommooweekh for aq
appdkanf wb has ad produced atxeptabk evhleace of eompnance wkh the htsitroee eoverap regtdrad"
Additional,MGi d mpta iS$12WM SIM"Neilba the commonwealth nor say of its pondal mbdhisiooa.shd
eooer into aay coattact Su the paformaom ofpubdc wosk tmm7 aw,cpubb evidence ofoompHanm wit►the inert uw
requvements of ells cbpter leave bocce presorted to>se eontractio�aiithosity"
Please fill oat the workers'compensatiou affidavit complet*by eLatiog the boxes that apply to your situ stion sod,if
Mccasary,supply subcowraciaQ name address(es)and phone mimba(s)along with their eatiticaoe(s)of
i amaocL.limited Liability Compaeiw(LLQ or Limited Lubt7uy Parmasbips(Ld.P)with no employees other than the
members or pwuas, we not regained so can workers' compensation immmce. If an LLC or LIP does have
employees,a policy is requW& Be advised that this affidavit may be submitted to the Department of ladoxtrial
Accidents for confirmation of immaorx coverage. Also be sore to udp and date the aAldavk. 'fie affidavit sboald
be returned to the city or town dial the application far me permit Or House is being requested,act the Department of
Industrial Accidents.. Should you have any questions regadiog the law a ifyon an required to obtain a workers'
oompeaaatio�I Policy,please an the Department at the ummba Hated below. Self-isnmed compames should enter dm*
scif-iosomm&me mamba on me appropriate 1ma
aq or Toiva Ofildahi
Phase be sore that the affidavit is complete and primed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event b Office of lums0gations has to contact you regarding the applicant
Please be sun to fin in the pamiNiceme I wbich will be used as a refamce number. In addition,an appbam
that most submit multiple permiu icense applications a any given year,need only submit one affidavit indicating cmrent
policy mformatwn(if uccessaty)and under"rob Site Addrese the appucaut should write"an locations m (dW or
town}"A copy oftbe affidavit that has beer of3eially sumped or marked by the city or knva may be provided to the
applicant as pimofeat a valid affidavit is on file for fsmre permits or licenses. A new affidavit nut be Mod out Bach
Year.Whore a home away at citisea is obi s Hoare of parmit not misted to any business or ao>®acial venture
(i.e.a dog license or pe®is to bnrn leaves etc)said pricer it NOT required to complete this affidavit
The Office of Investigations would litre to thank you in advance for your coopmduo and should you have any questions,
please do not hesiuft*give m a c sJL
The Depatrnest's address,telephone and fir umber
The Commonwealth of Massachusdb
DgwttnM of Industrial Accidents
Oifioe of avesdPdona
660 Washington street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Face#617-727-7749
Revised s-26 os www.mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-748-9895 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildin¢ Department
Debris Dismal 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:
LA;L6Pt J (Location of Facility) C S5-6 -
Signature of Applicant
2
Date