42 VALIANT WAY - BUILDING INSPECTION +LylNiWWIWff4EsMO APMVW aY Me o
CITY OF SALEM
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PLEM M L OLfr L EMLY a COMPLEMY TO AV=DMAVS N PROCWI p
TO THE INSPECTOR OF BUILDINGS: '.
�undoniprNd hW*Y •pplN• fW . Pit fo bM noofftlo ft.IoNowh
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SWOM of APgM W
simm uNw im PENALTY
OPPELRW
oEscwpnpN OF Ww TO R DO(NE�E
MAIL POW TO, 6;, bp L M,A
-lq1309Y, MA v I 9 G �
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i
No. 1��--�1
APPLWATION FOR
PEMW TO ,
LOCATION/ /
PERIAT N,ED
/INSPECTOW1 BIJILD/VCi 3
J
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): L.0 -✓ l r t �,�, Ly CO
Address: / 9 ty A I,. ST
City/State/Zip: Pe A k,>c 1� O Phone #: 9 1R S 3 k g 3 ii
Are you an employer?Check the appropriate box: Type of project(required):
I.X I am a employer with \ a_ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. i 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working afor me in any capacity. workers' comp. insurance. c 9. ❑ Building addition '
[No workers' comp. insurance 5. ElWe are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or adtiitiors
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
-- comp. insurance required.]
*Any applicant that checks box#] must also fill out the section below showing their workers'compensation policy information.
t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy intonnadon.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. [� nn
Insurance Company Name: I 1
Policy# or Self-ins. Lic. #: 6 0 c? O ( a Q O 6 Expiration Date: ' 3 .
�___
Job Site Address: 4 Q X/ A Li d4_d* W .AY City/State/Zip: . S o Lip on kl A O \ 71 D
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 1 7
Failure to secure coverage as required under Section 25A of MGLc. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, 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 certify under the pains and penalties ofperjury that the information provided above is true and correct.
SitinatUre: � Date:
Phone #: ��
Official use only. Do not write in this area, to he completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one): t'
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
PUIUC PROPERTY DEPARTMgNT
~ 120 WA "INQ1ON STIIaaT, 3RD FLOOR
. SALZM.MA O1 Y70
TEL (97e)745-E595 EW.360
FAX (e76) 74"e"
STANLXY J. USOVIC7 JR.• -
MAYOR •
. E
DISPOSAL OF DEBRIS AFFIDAVIT
of aerda co p Pins of M(X c 40.SK I aclmowledp That as a condition
governed by this Building Permit ashaS bedac s
6sposal facihty.as defned by MOL a a SSISOA. of is a property licensed wlld-waste
s
The debris will be diaposod of at Q .+ (�,�s� r & '�
Location of FamMy
Srgnahae of Pemrtt Appycast Data
FULLY complete the follawiM infonaation;
(PLEASE PRIMP CLEARLY)
Name of Permit Apphcaot
L Cy-
Firm Name, maw
Ad&czz. Cjtyj state
The above statute regyiza that debris from the demolition, rtmovation,rehab or
(d>e alteration of building or suucbm be disposed in a
facility as defined by MQ, cIM S150 and the bu�y-lic��Hcensesso"W am disposal
indicate the location of the fmdhw. �g Pamir or 1ice:lsa are to
_ �-y--
LEN GIBELY CONTRACTING CO., INC. _ Page No.�at� Pagea
149Main.Street- 19686 PROPOSAL '
PEABODY, MASSACHUSETTS 01960 - ?
•, All home Improvement contractors and subcontractors
(978)531.8234 engaged In home improvement contracting, unless s -
FAX{978)531-9304 specifically exempt from registration.by Provisions of w
.. Chapter-142A of the general laws, must be registered
Submitted 1v1 with the Commonwealth of Massachusetts. inquiries
To:_► 1` ^rtl kI'),4 ' I�C�.� vl't\ about registration and status should be made to the
w A V Director, Home Improvement Contract Registration, Er.One Ashburton Place, Boom 1301, Boston, MA 02108 a,
(617)-727-8598. Owners who secure their own . 1-
y J-1 /-I construction related permits or deal with unregistered IS
contractors will be excluded from the Guaranty Fund
(7 I 1 (7 Provision of MGL C.142A. -
PHONE' PATE gEeleTgglpN No. ��
9 � 3 �y'Ad—� 5 9 / 1) (la C) MA.REG. 100811
.lee NAaEMp:. yobs LOCAnoN - -
We hereby submit speaftadws and mtma[es for workbbe pedonrodeN meredab Nbeuead:.-sy, „+,- e _
a1�1bL.a H'u[.�v G W t b c r c�0`C
—L2S3 A !L✓ Y S L.( ^n L .a ��I vY D e �0
._Lt,i �c+ i'f..--�.(./,'.i17'-.La w Z- GL;ro
-_( I-l- �.�.✓ S�A S L, .r. S .4
___-_ (;v (.A rz A. �� - r n.r { 2 2 J� r c'CS �2 i ,���. _ — it
it -
Construcuon related pe -- ---- --'--
WORK SCHECULE
C.M..,will rwt the work or order Me Moderate before Me third day following Me signing of NI Agreement,union actual herein war tm or*it begin the work nor
bout n ate) earring delay caused by circumstances beyond Conti ones m tml,the work will b completed by �fdate) The Owner hereby,
�,s vied 9a agreed Met Me scheduling dates are appvlmate eal Nat seen delays Met ale noteeladad s by Me contrepor shall net be considered as wDlatons of this Agreement ;
me Contattor wemna Net Ne work famished hereuMer eM1ag W free Irom Defects n material ertl warkmenahip for a mdotl of Z��TY
following completion and shall comply wlth
Me requirements of Nis Areemaral me send any defect In woMmonship or materiels,or damage mused by Me Contractor,his subcontractors,employees or seems is discovered wlNin ,
one year aher compual M any lob,Including clean up Me Connector W.at his own expense,forthwith iemedy,repeh,correct replace,or muse to be remedied,repaired,or replaced,- '
such sources or such defect In meterlaA9 or woAmana'dp.The roregolnB warranties shall now.
am/Inspection peremteo In connection with the agreed-upcn work. i
r
We Propose hereby to furnish material and labor—complete 1n accordance with above specifications,for th,sum of:
dollars($ a.v
Payment to made Its follows:.; , ` 1J ni e ,�
r
M: ( f
`-�._ Nerta W GCn49Ctorleea B led R B imnl/ _.. . .. .._
�—°A(S )upon mmplefan of '
weer Address
)fWnmmplatorl
: �� ClrylStet / Ph
ohall ba made foawiM upon /
� l completion of was enter this mrtbact. PMM' µ_FPoareIIU No. -
Nofce: Noe agreement for home Improvement contracting work shall -T-o �' ' P
g p B regalia adown Nemeef Sul ( .
Payment(advance deposit)of more Man once-Mind M the total contact price or Me _
total amount of all deposits or payments which Me contractor must make,In advance. -
to order and/or otherwlas obtain delivery of special order materials and equipment aaMD'Izetl Sgremre `
whichever amount Material `r
Nou:ltJe prepoW maYPowandrewn by usllrot accepted wlVJn days
Acceptance Of PrOpOSaI`I have read both sides of this document and accept the prices,specifications and conditions stated. I understand 1
that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.. I
You,the Buyer,may,cancel this transaction at any time prior to midnight of the third business day after
the date of this transaction.Cancellation must be done in writing.
DO NOT SIGN THIS.CONTRACT IF THERE ARE ANY BLANK SPACES.
slenmwa �iy'opv ,FO3c'° i oat. sltaewre Date
IMPORTANT INFORMATION ON BACK RIP-