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13 VISTA - BUILDING INSPECTION IUVOM OE fMA94AD APPROVED Sy UK J mRgI; o6 AMR 7DA.PJU34W AgM GRANTED CITY OF_SALEM Is Property Looriad in lawgim o¢ rya IYMwb Dlrltlal? Yak_No_ aail�ioa Is Pmpatly Loodad In : a,.oo�wrwgn Awe? Yak_No_ BLMLDMK3 PERMIT APPLICATION FOR: Permit to: (Circle W*twm apply) Roof. RwW. In" SKft ComtrW Dsok. Shed. Pool - papaWpApWM OpW. /NS-4L - U.moo PPLVFi f)/;$7iN6 )� ,l SoY.92y r.. /7F 04190q„ PLEASE PILL OUT LEGISL.Y A COMPLETELY TO AVOID DELAYS W PROCES8MNG TO THE INSPECTOR OF BULDING& The undwsgrwd hereby applies for a permk to build a000rdirp to Ow folwmV Owners Name 14Mr--s 91 i 7�50s o, Address& Phone / 3 l.;57,9 9 vr'NcW- f97�j 74/s= 2 S-72 SALFri M j 0/970 Archi oWs Name Address& Phase j 1 Maahanir:s Nartw EQ ji ll (uscoy 00,9 Z ,oit?ri 77?a )7'iomS S:usnr 94',Aw., AddressBPhorw /y4(on,r.- S/— Po 63oy2a (9/�) 777 573-62. . 1 0,4AiV"S M/9 0 /521 mw is to purpose of tsrldtrp? Iwlww al pNldYp? Iva c,q ra g n,; M a dwaWnp,ftr law many bmin? vm kdit oordo m to law? y'r S Mbadoa7 Xlo Ensured and 41 o 0 0. o f ak�cry Lbnw r N A 8110M L1oMw r o3 a 7 s 6 Yowa #.lj swat V ® w lb / 1. 3 9 eA9 SIGNED UNDER THE PENALTY OF PWUURY DESCRIPTION OF WORK TO BE DONE 1N874 (.xlTioN OF Lvooro ()TGcF. i 1,N5F,S27 17,,iTo FV, si/r/ 6 MAIL PERMIT , G NO. APPLICATION FOR PEW TO Pe4Ls � LOCATION PERMIT GRANTED l � 710 z::� 20 AP ROWED INs;PEc.m OF E U LDIMM The Comntontvealth ofMassaenuserw Deportment of Industrial Accidents office of Invesdiddons, 600 Washington Street Boston,MA 02111 ww*%mass aotddia Workers' Compensation Insurance Affidavit Builders/Contractors/Electriciami/Ptnmbera Please Print Le ibiv A lican Informs o /Y(,e Traaa Petc�Fa, Y �r�6 AlAerZ6 19 Name non/I�ividnal): Address: eityistatetz* f,),v At 0,,a s 1PIA o/9 a 3- Phone et f Cheek the appropriate tax: Type of Project(required): r2.$01 u u employ p 4. 0 I am a Mad Contra"and I 6. [:]New construction am a eaPloYa with_1--• have hired the sob oontracba mployees(1A and/or part time)• listed on the attached shext.= 7. ❑ Remodetio; am a sole pmprietor or Parma- Thy sub-contraction have S. ❑ Demolition ship and have to empbYeet workers' roMV. bSOUM 9. p Building addition working far me in any casoce 5. ❑ We am a corporation and its or additions (No wtarlcae' comp•insurance otllcas have exercised their 30.� Elxtrical repairs 3.❑ Ir am aahhomeowner doing all work right of exemption per MGL I 1•� r�airs az additions c I52,I1(4),and we have no 12. Roof repairs mysei£ [Noworkeia comp• employees. (Noworkas' 13. /Otha PF�cr i STav� t insurance regnIIed.) comp.insurance tequired.J. •Any ePP> tMWchair box M1 mud tdw ce cut the eecNan i;an wak emd then bite otrtadeoutada' mnhaAo¢mud nibmM a mom'affidrvit m&c*tm9 each t Hotewaaen who eoltmit tlda et6devtt htdicda a they dorm tConvec on to check laic boa mud aneched m edditioed skeet dtowvta the nanm of the abeonnactaa cod tbatr wott[en'wmR policy iafottrrottoo. rovldlna workers'compensalon Laurance for aey s+erpkl'�' Below Is the popsy and Job s!b 1 are an eayslo,►'a dig is p LnfanaNea Insurance compaoyNatlle: /�hrrarCr`r,U /(/Ol�Ir' /�S3 �CtgxGr Policy#or Self-ins.Lic.#: e V � Expiration Date: 4Z /t/I ao o fO / 3 Ili 5 14 /� Y.x uF, City/Stateft: 5�9 r"•� /a A ©/5 7G lob Sine Address: V Attach a copy of the workers'compensation policy declaration Page(showing the policy number and espiratton date). Pa ne m secure coverage a4 required under Section 25A of MGL c. 152 can lead to the imposition of"blind Penalties of a fine up to$1,500.00 mdtor one-year imprisam .as weft as civil penalties in the form of a STOP WORK ORDER and a fine of up m$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage vadic llim AP hereby csrdJ} under paba a dppenahlo of p�apluary skirt the Lrfanwdon provided a"m h lour and coffft 101�9�._✓��.//lam//0" ��t�i!//� Datr• /alG/o J �.o # 575 - 777 - ssG FinuWisgAidbority De ad wrbs Lr thk area,to be eonpkmd by elry seam 0AWd Peradbueeme# y(circle one): Ins tuxtor lth 2.Building Departmeat 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing p. Contact Person: Phone All 11niVa 11a466aVln "&A%& -111A61 M%WIAVis0 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an earployee is defined as"...every person in the service of another under any contract of hire; express or implied,oral or written" An earployer is defined as"an individual,patnembig,association,corporation err other legal en*or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or.irosta of an individual,parmersh*association or other legal entity,employing employees. However the owner of a dwelling house having not non than three aparunents and who resides thamm,or the occupant of the dwelling house of anther who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employa." MGL chapter 152,$25C(6)also states that"every state or local licensing agency shag withhold the Inman"or renewal of a license or permit to operate a business or to constrnet buildings in the comnonwealth for any applicant who has not Produced acceptable evidence of conwilance with the htaaruee coverage repaired." Additionally,MGL chapter 152,125C(7)states"Neither the ecomnon wealth nor aay of its poMW subdivisions shall enter into any contract for the performance ofpublic work ut.d acceptable evidence of compliance wig the insurance requirements of this chapter have been presented In the authority" Applicants Please frill out the workers'cotpensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)=n*sb address(es)and phone number(s)akrog with them cadficate(s)of insurance Limited Liability Companies.(LI Q or Limited Liability Palnersluips(Id P)with no employees other than the members or partners, are not required to carry 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 Deparhnat of hrdostrisl Accidents for confirmation of insurance coverage. Also be acre to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not tie Department of Industrial Accidents. Should you have any questions regarding the law or ifyou we required to obtain a workers' corupemsadon policy,please call the Department at the number listed below. Self insured companies should enter their self-"insurance license number on the appropriate line. Cky or Town Offielali Please be sure that the affidavit is complete and printed legibly. The Department has.provided a space at the bottom of the affidavit for you to fill out in the event the Office of Invesdgatious has to contact you regarding the applicant Please be sure to fill in the permidliceme number which will be used as a reference mumber. In addition,an applicant that must submit multiple permiNicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town}"A copy of the affidavit that has been officially stamped or mated by the city or town may be provided to the applicant as proof that a valid affidavit is on file for 14tre Permits or licenses "'new affidavit mast be filled out each year.Where a home owner or citizen is obtamiag a license or permit not related to any business or commercial van are (i.a a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would blue 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 fits number The Connnonweatth of Massachusetts DeImbnettt of Industrial Accidents Oiaice of Inveftatlong 600 Washington street Boston,MA 02111 TeL #617-727-4900 ext 4o6 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-2605 www.man.gov/dia 0 CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT o' 120 WASHINGTON STREET, 3RD FLOOR M SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Buildim Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: I &L-n 097,tt A T : (Location of Facility) l yq A",V F: S? k / Dom, �2s� J+-rA C> 9d3 Signature of Applicant Date