1 SEWALL ST - BPA-06-556 REROOF f1lMIB�tlBT'EflU1i41ND APPAOVEdi sY Re
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CITY OF SALEM
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Permit t0: BWPP
.DMrG Pill APPLICATION 1101111:
(Ckola whbhawr apply Root, amof, lined S ft CWAUW DSOK Shed. pool.
PLEASE RL OUT UMLY A COMPLETELY TO AVOID DELAVB N PROCEISM
TO THE INBPEWM OF BUILDINGS: '.
hweby applies for a pormk to build accof ft to the fol &*p
quoulloadom
Ownara Now
Addroaa& Phan (�b�
Arahllaot'a Name ✓� �/
Ad*m& Phai Z A ,� f
Ma m io Nam. �i���✓LT /A �L(J�L U
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Slpnatwo of Applbant
TiIE TY
MCRry ION OF WORK TO BE DONE oppoullm
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MNL PERMIT TO: 3�s` Gfga7, 5
SON nym iO !lOLO3d8N1
as me imirad
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of immod
HOS NOLLyoru"
UeparrmeM of inarsmm Accraenrs
Offl t oflnvestigadons
600 Waskingion Stied '
Boston,AM 02111
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Workers' Compensation Insurance Af6davtt: BWMers/Contractors/EledridansMumbers
AnUcant Information Please Print Lesibiv
Name : �� 0/c �� G �� a2
City/State2ip:/�z mel 5 ./y7 A Phan# 74 `1 Z y ��/2
Are you an employer!Check the appropriate box*. Type of Project(required):
1.❑ I sur a employs with 4. ❑ I am a penial contractor and 1 6. ❑New coaat<ocuon
employees(till and/or part-time o have hired the sob-coatramrs
2.❑ I am a sole proprietor or Parma- listed on the attached shut t 7. ❑ Remodeling
ship and have so employes These sob-eontractms have S. ❑ Demolition
for mem ��' iasmence. 9. ❑ Building addition
war for any capacity comp•
[No workers'comp. M-110 race s. ❑ we are a corporation and its
required] ofters have exacised thea 10.❑ Electrical repairs or addition
3.❑ I am a homeowner doing all work fist of uempdon per MGL 11.❑ Plumbing repairs or addition
myself (No workers' comp, Q 152,11(41 and we have no 12'%Rcofrepairs
iasuranurequired.]t aVbyam [No
13.❑ 011ier
Mmes.immance required.]
•!my appNcmt dot chub box el mus also 811 out the nodoo below*win$tok rales' policy WMMgdes.
t Homeowners rho edad this GM&vd Wicetma they ire doing A work sod On hoe ouh fc coo0ueteo mart submit a sew,a8•dava mdw4xfng such
tContraebn that check do ban roue sunchad es additional abet showing the nems of the sdk mcov usots and thec wotlten
� 'oon*L Po&y iuronnetion
few ax employer"6 providbig workers'compmaBoa Inswuneefor cry employees. Ndow 6 Aepoblry xxd job slat
InfWMANUM
Insurance CmW=yName:
Policy#or Self-in.Lic.# Expiration Date:
Job Site Address: City/StaWZip:
Attach a copy of the workers' compensation polley declaration pap(showing the pally number and
expiration date).
Failure to segue coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s
fine up to$1,500:00 and/or onc-ycar imprisonment,as well a 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 Ofi m of
Imeatigadous of the DIA far insurance coverage verification.
I do kenkyto tits p w p*x&Ma ofpedWy then the krforwat6se puoyi&d about 6 eras ead cornteR
Si D — / 7 — v�
00cid use only. Do ear writs In Mir erre,to be completed by cloy or rows oaleld
City or Town: Permilluc slse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cky/1'owa Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other,
Contact Person: Phone#:
Massachusetts General Laws chapter 152 requires all employes to Provide workers'compensationfor
cthen'employem
ontract of hue,
Pursuant to this statute, an,earQfoyes is defined as ...every Person in ibe service of a>0 under any
"press or implied,oral or wnithm" .P ..
" arue nbfp,association.corporation err other legal entity,or 28Y two or mote
An c++pWgr is defined as an individual,p of a decened employer,or the
cagagod in a joint enterprise,and nchWmg the l�representativesHowever the
of the foregoing ag�jytion or other legal entity,employing cmpbyem
receiver or trnstoe of an individual.PSS and who resides therein,or the ocaPaet of des
owner of a dwelling house having not mote than dime dweRing house
dwelling house of arother who COV"Persons to do maintenance,coustr�ion or repair wor(r on and
or on the grounds or building there"ahafi not because of such employment be deemed to be an empbyner."
MGL cbspies 152,125C(6)also 51210 that"every state or local licensing agency shay withhold the hsnanee or
renewal of a license or P to e a bwhm or to construct truct buildings in the commonwealth for say
appBead who has■ut Produced acceptable rAdenee of eomPBaaee wtsh the insurance covcraga lWcd bdi vred."visions _
Additionally,MGL ehaptxr.1s2,4ZSa7)S12 be�old
��evideo�of it'
wift die
entre into any contract fir dw Peri >
requirements of an chapter have been presented in the contracting erudtofity--"
Appfleanb
Please fin out the wotkers'compensation affidavit completely,by chen>drig the bolo that apply to Your situation and,if
necessary,supply, sub-cosmnm
actur(s) e(e),address(es)and phone number(s)along with their ca"cate(B)of
necessary LkdwdLubft Compaines(LLC)or Limited Liability Partnership W)with>n employ=other than the
members or parmen, ale not� to cavy worken' wmpms dm bsw=m If an LLC of LLP docshave
employees,a policy is requited. Be advised that this affidavit may be submitted to the Department of htdnstrial
Accident ger confirmation of ioa Bance coverage. Alm be sore to sign and date the afftdavlt. The affidavit should
be returned to the city of town that the application for ihepermit or license is being requested,ant the Department of
ludusnisl Awde nta. Should you have any gaeadusu regarding the law or if you sit required lo obtain a workers'
compensation piitiey,P)�.call the Department at the mmdrer> bek►w. Self insured companies should mar cher
self-insurance tIcense mruber on to
line
City or Town Officlala
Please be am that the affidavit is compIcoe and Printed legibly. TheDepartrnent has provided a space at the bottom
of the affidavit for you m flu out in the event the Office of Investigations bas to contact you regarding the applicant +
Please be sure to fill in the pumu/ticeme number which will be used as a reference number. In addition,an applicant
that must submit multiple POrnit/hcense applications in any given year,need only submit one affidsvitindicaung current
policy mfotmatron(if necessary)and under"Job Site Address"the applicant should write"all location is (city'or
town}"A copy of the affidavit that bas been officially stamped or mafked by the city at town may be provided to the
applicant as proof that it valid affidavit is on fib for fhUro permits or licenses. A new affidavit=9 be fulled out each
year.When a home owner 9j citi m it obtaining a Hcense or permit not related to any busioesa of commercial venture
y
ya a dog Hoose permit to bran leaves eta)said person u NOT required 0 complete this affidavit
The Office of Investigation would Hite 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 fan number:
The Commonwealth of Massachusetts
Depuftnent of Industrial Accidents
Ounce of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2605 www.mm.gov/dia
CITY OP SALtMV MASSACHUSKWS
PUsuc PnoramwOtRARTMtNT
120 VAaNINgftW all M, 3110 FUMM
OALa11.IIA 01170
M (070)740.0000 CV. 300
Is RAR 070p 740.0040
STANLCY A UnOVICZ. JIL
MAYOR
DWOM Ofd Dl3 M APMAW
IS 10001101ee wilfl the pr0Wd=of MM a 44 W41 aeltso *p than ale a coodid m
Of if�l�amit� .elf doheL�fid�e0o�a aettviey
pmaid by(his DoOfthermit dM be d gm d offs a pd sly Hedad eoa&4nm
dWp W hefts ar de fssd by Ntfii.a UL S1SO L
1b dal6efe Mill be diepoaed ofale ` S`:°:�!tea—`/ �" T
Loeadoa ofl+alci>ity
Sipdm off amst Dme
nUY 6011104011 Ibe MOM %MhMWiM
MlA=l'Rw Ci.11ARLYj
- N.ma of Psmit Applfaot /// l' /2-��
LJNsC f4 6-/ ✓y<j2 Zl�j . 5 hox>
Firs Name,If my
Addrat.City A Stow
The above SUM rogmm that debris ftm the daaoliuM amoval M r&*of other
&as dm of buil ft or smwb n be disposed in a p1Opaly.0 mated soli&ws"diep W
f>talny al de&W by?40L dM S1 SK and the bWWicS pamitr of liceosfa in to
iadiata the loeadoa of the 5dity.
Jice P °
BOARD OF BUILD I G REGULA
Llagnar CONSTRUCTION SUPERVISOR
N � 052872
t Btr -E?1Fa1 953.
ns" 01t3T12(102 LL
Tr.no: 8436.0
ROBERT A PAN ZLE>
1 PINE RD F � Gr iJ
4. BEVERLY, MA 0191 Commis•lomr '
14
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#1965
CITY OF SALEM"
d BUILDING LICENSE
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