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7 VISTA AVE - BUILDING INSPECTION fL�IIrBlfttlSt�EfKA04#0 APPROVED BY CIE rrelsf3ECILIB MWR TD4 PPJLW BEWO WANTED CITY OF SALEM No. 99"�� _ ow 1 s N. b l oody UcYod In ✓ 110"tim of � )( 5 i x ffw Nblodo OiMdcl? Ya No_ aail/faa V is Pmpaty Uomd to �� J waGonlWWftnAM? Yq Now OU LU" M WT APPUCATM POR: Permit to. (Circle whiotwvor apply) PA,,�S0gi Can" DOCK Shed, POOL PLEASE PILL OUT LEGIBLY&COMPLETELY TO AVOW DELAYS W PROCEEEM TO THE INSPECTOR OF BUILDING& The urtdersiprwd hereby applies for a Wmk to build accoa tp to the buowi V OWWSNoma !Address & Phone -7 `/ !S>>4 /Y U. ?A 015� Amhitods Nww Address & Phone j 1 Mectwnim Name xs cn:wo"ss _;;M q MA 01607 rftt Address A Phorw �7&1 SZ.9-S -7 Co 6 what b fhr prpm of WYtlYp4 �- ttom of bYYdYp? 1j1XjV1M a dwrrYlp,for few awp/r gimWrr7 MIN O Aft oo m tome AlbmW? tafrnard ooa$_ N U city uorw r N ` uouw r one lmprwey�t SWW MM THE PENALTY OR PMLNW DESCRIPTION of MIOR1(TD BE DONE MAIL PERLAIT 6� e-79 0 r !•rl11�{AUN NR�A4:f"xS� r � r r The Commonwealth of Massachusetts Department of Industrial Accideins Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Bulflders/Contractors/Eledridans/Plumbers Applicant Information Please Print Letlably Name(Businessiorganization/Individuan: B 0 n1[ Address: OD lLit5 Lc"ELLJ — City/State2ip: Phone#: R 7 �'5-b q ' 5 7� Are you an employer?Check the-appropriate box: Type of project(required): 1.® I am a employer with to 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. t ?• © Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.� Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I E1 Plumbing repair or additions myself.[No workers' comp. c. 15Z§1(4),and we have no 12.Q Roofrepairs insurance required.] t empb ces.[No workers'insurance required.] 13.0 Other comAny applicant that checks box#1 must also fill out the section below shewing then wodom'compensation policy infonmtim Homeowners who submit this atHdevit indicating they am doing all work and then hire outside conbactots must submit a new affidavit indicating such . :ontrectus that check this box must attached an additional sleet showing the name of the sub-contactors and their workers'cow.policy infotttmiion. am an employer that Isproviding workers'compensation insurance for my emVloyees. Below is thepolicy andjob site formation rsurance Company Name: n i—� ��rS l.. 0Q ()_�F f-A olicy#or Self-ins.Lic.M Expiration Date: rb Site Address: city/State/Lip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). *lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae 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 Fup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for msuraace coverage verification. do hereby cerrtfy under the pains and penalies of perjury that the Information provided above Is hue and correct 'goatme• �" Date: cone#• `1�� O l� ( � �? V & . — O,Qrclol use only. Do not write in this area,to be completed by city or town gffWal, City or Town: Permit/License# leaving Authority(circle one): 1.Board of Bean 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector 5.Plumbing Inspector C Other Contact Person: Phone#• CITY OF SALEMv MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA O1970 TEL. (976)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition of Building Permit# ,all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S 150A. The debris will be disposed of at: V)(I'eC£:'TE4L Location of Facility Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) �� CH How Name of Permit Applicant tAovy)>? `7ePCrr Firm Name,if any �Oe-CgSTE2 Address,City& State The above statute requires that debris from the demolition, renovation, rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL ca S 150A, and the building permits or licenses are to indicate the location of the facility.