14 SUMMIT AVE - BUILDING INSPECTION (2) Unt
1
• irp of a�ArPl7i, ���tL�UfsP �
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMT BEING GRANTED
Building Prrmu Application For. Location of Bupdin= 14
'(Circle whkkva ") hoot Reroof. lamil Siding Cot suw Dock,Shed,Pool
Addition,Alwatioa, qmlation Only.Wracking
Othp;
PLEASE FELL OUT LEGIBLY& COMPLETELY TO AVOID DI,LAYS IN PROCESSING
To the lnspeaor of BuiWiogr. - � � .
The MdWdpAd haft applies for a perrnil to build aocordioS to the FollovrioS apeci8ptions:
Owneri Name��� h Caw
ractor.
saea`� elm��r� ll d � cin suaa�lJ �f?X 11t City __
sawk . ph,.q-9 ) - bin State - Pbom
Arebitecr City of SabaLiar
street 01Y State 0— W3mv r I 'N4 2 7 C)
Stan %01C ) Ho.eownen Exempt Foro..�rn no
Strrteoue:(please circle) Faatily, F,in;ly 0 _Other
EstisaMW Cost of job f Q . Q
AsbowuO
gosenpws of to CtV
�U. � �tv��z.
car . � n 1 �-c �--
Drawinp mi«ed: so Man Permit to:P� x (�
GNED UNDER THE PENALTY OF PERJURY Q 047!!D
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
antatS►tsv oantau.
ua VAS MCT SMW a SMMA MA91ACMUM01970
To.97t-743-9M a PAa:9W 0.9"
Worllera' Compensadon Imnranee AAtdavit: Bngd"WContrattonMeeWd&=MhUnbM
Auoikant In— -don Please gems r Obly
Name awq: �r� C�xrr
Address:_ a l (� L \l11
C►ty/Statorzp: / M, Phone#
Are you an espieyar?Check tie appropriate boas
1.❑ I am a employer with 4. qj I am a gone"(c!006W--�
r and I TylM of(trolled(�mkw.
employe"OhB and/or part time).• have hired then 6. ❑New caasntsetlm
2.. 1 am a sole propriator or partner. listed on the aueet,t 7. Remodeling
ship and have no employees Thep
working for we is any capacity. workers,compa ❑Demolition
010 workers'comp.meoranp 5. ❑ We are a corpod its 9' �Building motion
required.] o8kera have extsir 10.[]Illecnicai repairs or addidooe
3.❑ I am a homeowner doing all work right of exemptiOL 11.0 Plumbing repair or additions
Myself (No works='comp. o. 152.41(4).ane no
fim"Ince 1 t "+ply(No ' 12.�Roofrepaie=
dodo
comp inauas" ) 13.0 Other
t Hamwa who=bnk dds e mo aAldteit�"fin as We w reef babw eheadn=set ea tm'meymeaaea patty lahmadi t
rCaau+etar do�#tdr Ws boxfnt+rue f dd(tlfd drft'L aakd dm hbaW&conau m no as"a new afil6va indkoks I L rhowirs the nrm e/the sob4ow mop and dak wadcea'fmp ply iefinrewtlm
l am an feep/oyar rlMar lr provWxS workers compmsadon ben a a
hejornadem A Aey ewployaaA bldow 6 Aepolky and fob sJh
insurance Company Nama:
Policy#or Self-ins.Lie.#
^n-- ` Expiration Due:
Job SiteAddreax �7VV l fM�
Cih/3ftwz - �\
Attach a ropy of the worker"'compematiosi poary declaration page(rho tie
Failure to secure covens a Belot pow asm�and eaptratim dab).
Jp required under Section 25A of MOL e. 152 can lad to the imposition of criminal
fine up to S 1.500.00 and/or one-year imprisonme►t,as well as civil penald"is the Porn of a STOP WORK ORDER tied of a
to up $250.00 a day against the violator Be advised that a copy of this staxemem may be forwarded to the OfYtee of
Investigations of the DIA for insurance coverage verification.
/do hereby ob PW xs and paaalder ojparjwy afar a*la/onaodow provldad &A,"and correct
1
O,fIchd use only► Do not wrke 4&&arse,to be co Aep/atef by eUr or lore ofJfe/aL
City or Tows: Permit/I.Ieense#
issuing Authority(circle one):
1. hoard of Health I.Building Departmtot 3.City town Clerk
6.Other 4. Electrical Inspector s Plumbing Inspector
Contact Person:
Phone#:
Information and Instructions
�ayywhusens General Laws chapter 152 requires employers de wohers eO ° OO for their employe-M
a sua h s this emitter.an aaepleyee a defined>•"...every person
in the serice of another under any conttae�of btir�.
express°t implied4 arm or wntten•" or other Jew entity or any two or more
An anpfoyer is defined m"m individual.partnership;aswctanos4 va of a ds�employer-
of the foregoing engaged m!iouat eoterpsw' ad wbo_
assoeiadin or 19 Indnocc �
receiver at trustee of an indivi&A Parma**owner of dwelling boom hisvmt not �apartments
eomotttctiaa error rePslt`�as stteh dawtlio{ito°ss
dwelling b ouse of aoodeff e�employe 'hall mot because of soeh employment be deemed to ba m entpbYst'
or on the g�or building:pp�tttnmt steal wuhf+old IM Waana or
MGL chapter 152.12SC(6)also states that o�bed HCGMAIMIafe�y ' �
beildup i�the COOOO � w
reteewafl air a tlauss W pert to operab usis N tta comma rein to is ewaw e.WsV e4
appifeant wbe hu not pradoet, s�"Neither the eomn=W"I h mar'Y of ita Political s' vidOOs shell
Additionally,MGL chapter 152.�25C(I) at welt until aeeeptable evrdence of compliance with the insurance
t,w."- w
eater into any rosined him psdmbd to the contracting authority.
requirements ter
of this chap
APp ic" fildvi, qd.Wy by ehselting the bozo that apply tn'YOM' 0°sad'tt
Please fill out the NCO s mmAs add a phone° alongwiththeir employeescalifica*s)o of
ther then the
partnerships(11Y)with no
necessary..supply Liability C.a (LLC)or Limited Liability
iasunnce workers'compensation inanrancs• if an I.I.0 or Id.P does ltaw
b of bduaaia►
carry
are net to the Department
member a[ pork a. 80�that this a@ldavit may be submitted the of MSVIL The affidavit should
�p�p,a polity is elon � ooversge• Abe be sate to sip and dab Department of
Accidents for con&matlon Of bthet application fbc the pew or license is being rOPMbe rcurmed a hers.
Industdal Accidenthis n Should Y ou have mY 4nc 0O� liaoed below the IM or if You am required to obtain Selt- canter sbould°nest their
compass den policy.Please call DePara�t line
Belt-inNremp firmer member osl the
City or Town Oleeleb Ths Department has provided s space at the bottom
Please be tore that the affidavit is complete and printed legibly.Ime has to contact you regarding the applicant.
of the affidavit for you to fill out in the event the Office of Inveatiged ass muaber. In addi&%an applicant
erne number which will be used ,n reference
Please be aurae es fill in the permit/lic aPpllc'tiOns in any given Year,nerd only submit one affidavit inidieating current
or
that must submit multiple pandul C°HQ the applicant should writo"all locations in__(city
policy. (if mcgssry)and under"Job Site Address" er m�red by the city or town may be provided es the
town). A copy of the affidavit that has been officially MUWW er licenses Anew aF;idavu must be filled out each
applicants as proof that a valid affidavit s on fits for flidse Permits mot related to any business at connumsl venture
year.Whore a home owner or citizen is obtaining a license a permit
(i.e. a dog license or Permit to burn leaves ere.)said person u NOT required to complete this affidavit.
The Office of lnvesdganons would like to thank you in advance for your cooperation and should you have any g4e96*14
please do not hesitaw to give us a calL
The Deparmsea address,relePhOAe nd rez number.
The(,Anmonweaa d Musacb=0
DePSEUNIMA of indosltid Amdentil
Otlsa of 1311" Pdod
600 WL41119"Sftd
Boerne MA 02111
Tel. N 617-727-4900 Cd 406 or 1-877-MASSAFE
Fox N 617-727-7749
ltcvised 5-2&05 www.nl m&pv/dig
Crry OF SAI.P.M
PUBLIC PROPEM
DEPAATDEIT
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