22 SUMMIT AVE - BUILDING INSPECTION (3) 1
use at the guddk�p9 '` ` 'ram•
What is U»arrant it& sorq,how many units9
VW*0 O Mft cad was to t.aa/i' y P s Asbestos? _
Atd t ds Name 1
Address and Phonemodmies
Name 0Addrem and Phone
7 � l•-c � R�r
ud aa
fon supwvis LicenseLicense Q
� HIC ReOMtatlon d- I •Z�s
^� cxx� �' Perm!Fee C +Wfon
Eswnsied Cost Of Pm*d�-lC--PMmit Fee Estimated
� x s7151000 Residentials -.—
_ - - - E.w+.t.d cot x s„/s,o06 cea+n+.rdat -- - ---An AddNk nai s6A0 Is added as an
AdministrsUw durpa
Make sure that an ftWo are properly and I jg"v~to avoid delays in PnCc@ssina
The undem pry doaa Eby apply fbr a Buddir Pwn A to build to the Owe stated
spedlcatlona. Signed undw pewft of pelt" (:)
Date f C,ft
2 S�
� �
Crry-oFsAum
PUBLIC PROPERTY
DEPART m&NT ,4?�//,n_,
Kursnavosaasa
l .M'?$•f!/e 0 F*M M74041e0
A*PLC•�►_TI IN FOR 1A*Am- ) NMOVA'TIM_ Ma'MiLUnnrt
D9340 1'IM OR CHAl Of U3S OR OCCCV_ erns, ANY ZX MMM
1.0 SITS INFORMATION
Locadon Nama I
--- FlWaly Ad&*uc---- --
' Z se ,--,./hi VL
Property Is bested in a;CmswvaNn Arse YM Higorb DlNld YIN
"OWNERSHIP INFORMATION
9.1 Owner o/Land
Names
Address:
Talephorn:
ff
ET!THIS SECTION FOR WORK IN MUSnNa SUILDINOS ONLY
Existing Number of Stories Renovated
Change in Use Near
Demolition Ex;,yV
Approximate year of Area per floor(sf) Renovated
Construction or renovation
of existing building New
add Description of Proposed Work: U� Co�jc\. ROD
Sr.Jgy,L� �r�rc I�r rc nr ` • �q�� N2:� ���f`�- .
--- -- ---Mail Permit kx 2 Z -iA, bi+r. ,,�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�tunr'at><r uatscuu
Vl.trca I2C V7A%&%A;'WNSTa9aR a SAlsst,L(AptM,7p.:iF:7'1\01970
'rtL--97t6743.9595 a FAX:97i740.9946
Workers' Compensation Insurance AfdavIt: Builders/Contactors/Electridumvplumbers
Analleant Inrormation Please Print Legibly
Name ttluainesstOraaniruiavlmLvuhnl): r Or4 s . 1'ry L
Address:_ al 7-4 t'15� .Cst ra C'�- c F
City/Statc2ip:MA")eZ-kog- _ " Ca 19fS Phone N: ?�f i — �39' � G 7 7
Are you as employer'Cheek the appropriate Dote
Type of project lre9uirtit$
1.0 1 am a employer with-4--L 4. 0 1 am a garland contractor and 1 6. ❑new construction
employees(rult and/or part-tine:). have hired the sub-comractors
?.❑ 1 am a sole proprietor or partner- listed on the attached sheet 1 7• %Remodeling
ship and have no employees These nab connsetaa have V. Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
(No workers'comp insurance S. 0 We are a corporation and its !o. Etectrigl required.) officers have examined their ❑ repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(no workers'comp. e. 152,§1(4),and we have no 12 0 Roof repairs
insurance requited.) t employees.(No workers' 13.0 Other
comp insurance required.)
'A�n vpewcA the chocks boa rt man raw rill osa ur secure 4;tow crewing inks wwt@W rump ftaliva pU+i y inrwatwiw►
11umuusnete who submit this atndwe ineicatae tla y am doing all wok one etm him euleiCe camaocwn mot.ttdttit a mks amdava indiaadina sot.
4Cun1nmm thin chant this beet met ueachad an additional sleet showitq dw agent tddla mbooeuapas MW their wutkan'camp.policy intaanwit a.
I sae an eaop/oyer that fr providing,worriers'compenraden humranee for my employees Below Is the puNty and Job site
inloraeatlan.
insurance Company Name: 6A i t� y
Policy p or Sclr ins. Lic.M: C Z3 WC, 9. .._... Expiration Date: ?0 S O R'
Job Site .Address: �2 SuMh.:r A vP,� CityiSt6tuZip:5(*'11ca� An.4 0/5P!26'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Fat lure to scour coverage as required under Section 25A of.\1GL c. 152 can lead to the imposition of criminal penalties ora
nine up to S1.500.00 and/or one-year imprisonment.as well as civil penalties in the form ofa STOP WORK ORDER and a fine
,)full to S250.00 a day against the violator. Ile advised that a copy of this slawment may be 1'urwarded to the Office of
Itn.,ugaumis of the DIA for insurarce ancra p verification.
/do hereby rcn/f r r the pains and 1woudlex of perjury that alas in/arararlon provided above is true wail correca
�i•:rutty• `�/ r /l.l Date• �Q.�S0�t
-n�,--) �
U/Jiciaf rase owl% DO war write/a this area,to At campleted by city or town o/jli-lid
City or 'rows: __. Pcrmit/1Jccase M
Issuing Authority(circle one): —
1. Itoard of llralth I. Building Department 3. Civrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cuttlaet Person: _ Phone q-
r
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers
did service another under any workers* compensation far chair Ct�of M�
pursuant to this statute.an rwpbyee is defined as"...every Pe
eapross or implied,oral or writtcm"
kn dyer is tlofieed m"as ice.peteawebip.assoetabou.corporation or other legal entity.or any two or mere
Of the foregoing engaged in i joint enterprise.and including the legal representatives of a deceased employer,of the
uweinnon or other legal cMcty,eaoploying employees. However the
receiver or tt tsetse of an iu baidu4.es.ong ah o ' and who resides theeein,Of the occupant of the
owner of a dwelling house having sot more then throe apsrtneeb or re work on such dwelling house
dwelling house of another who employs Persons to do maintenance.aiossrtictia► P layer..
or on the groun
ds at building appurtenant thereto shall net because of such employment be deemed to be an emp
iss
or
SILL chapter 152,¢25C(6)also states that.."ary seats or local licensing agency� ommenweawithhold thekb for MY
resew at of a license or permit to operate a business or to construct buildings
applicant who ban net produced acceptable evidence of Mulligan"with the Insurance coverage required.
additionally.MGL chapter 152,§23C(7)states'Neither the commonwealth star guy of its political subdivisions shall
formancc of public work until acceptable evidence of compliance w ith the insurance
ennui into any for the per resented to the contracting authority."
requirements of this chapter have been p
Applicants
compensation atlldsvit corn bsely.by checking the boxes that apply to your situation and.if
Please fill out the worltero' comps P
necessary.supply sub.contractoc(s)Min addceaala)and Phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employca other than the
members or partners,ate not required to tarn'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. Ababa sure to sign*adduce the allidavit 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 Accideats. Should you have any questions regarding the low 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 line.
City or Town Oifkleb
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fell out in the event the Office of Investigations has to contact you regarding the apPlicant•
phase be sure to till in the pormit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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 I 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. When a home owner or ciu=n 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.
I'hc Oi ti,x of Investigations would Cue to thank you in advance for your cooperation and should you have any questions,
picabe Jo not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OAkil of levestilgade as
600 Wallington Street
Bostonr MA 02111
Te1. 1Y 617 727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
tcvibcJ i-2G-U5 www.ams.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..UM,a a[- ArJ)tL
at...• t3Crmlcw-:owSatatT0�u:� ��:a.stZs::9
Construction Debris Disposat Affidavit
(required for all demalMon aid tenovatim wall)
In ueonbum with rite sloth ad dam.otdw Sate Building Cod@.790 CNIR scotion 1 t 1.S
Da d4 and dts provisions of NICL a A S 54
13WWas Patnit A _ is issued with dw coididom dmt dw debris revAldng Sots
this want shalt be disposed of in a properly licensed waste disposal fbcility as defined by%tGL a
111.S ISO&
The debris will be =Mportad by:
C lLF7 C• n1-'S1�2C NION -u7r-lC�
_. tuome of Ibu1M
rhe:k-bris wilt be disposed grin :
t rt:,,tit�t•rkttlty)
r,.LP¢fs .li t'x:Ltyl
25 02 _
a