56 WARD ST - BUILDING INSPECTION (2) fL*Nsi tiffIlEf 1ID APPROVED BY T44E
JOISTPGWTDAP.F.IA TAEINGGRANTED
r - CITY OF SALEM
No. b s DAMIs 16
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BU LDWQ PERMIT APPLIMM POW
Parma to:
(Circle whWwm apply) B24 ,RN at oot. InsW SWk4 Cwwm Dock. Shed, Pool,
`F lodes,
PLEASE FALL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCIIIIIIIIING
TO THE INSPECTOR OF SIR' NGS:
Tho wWwaiprwd hmby aWm for a pwma to build awxft to the W wirq
opecambow.
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O Wa Name y
w Q�q ft cotia� tR���
Adtlrass 6 Phone -5-6 wXX d f 9 7,f ;7 YY
Arohaeds Nam
Address& Phone j 1
Madmics Name ,
Address & Phorw j
Whet Is to P OM of brl0trp?nQ A)j a S
VANO 01 M~ tr�c.la M•dM/WIlO,IOr t10Mf many ponlws? ,T v=
WE b des:oaram to law? AWNft s?
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Lie. 0 l(AW4(i L
of Applicant
SW= fAd M THE PENALTY
OF PWLRW
DESCRWTION OF WOW(TO BE DONE
CAVNA, S (- �-
AS io canloa ,, --n sia)te.-�kla coltS
MNL PERMIT TO:
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NO.
APPLICATION FOR
D PERr/ T TO
LOCATION
SG G✓�,ea s T
PERMIT GRMJTEO
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TERMS AND CONDITIONS
1. Unless otherwise noted within this document, this contract shall not imply that any lien or
other security interest has been placed on the residence.
2. Aoolicable Law This Agreement shall be governed and construed in accordance with the
laws of the Commonwealth of Massachusetts.
3. Entire Agreement: These terms and conditions represent the entire and integrated
Agreement between Homeowner and Bravin Home Services and supersedes all prior
negotiations, representations or agreements, either written or oral,and may be
amended only by written instruments signed by both Homeowner and Bravin Home
Services.
4. Legal Actions: Should it become necessary for Bravin Home Services to enforce any
term of the provisions of this Agreement, or to collect any portion of the amount
payable under this Agreement,then all litigation and collection expenses, including
but not limited to witness fees, court costs, and attorneys fees shall be paid by the
Homeowner.
5. Bindino Agreement Homeowner and Bravin Home Services respectively, bind
themselves,their partners, successors, assigns and legal representatives to the other
party to this Agreement and to the partners, successors, assigns and legal
representatives of such party with respect to all covenants of this Agreement.
6. Severability: If any provisions of this Agreement are held to be in violation of any law or
ordinance, they shall be deemed stricken and all remaining provisions shall continue
to be valid and binding upon the parties. '
I understand that this is a legally binding contract and have read and fully understand the terms
and conditions contained therein.
Homeowner Date Bravin Home Services Date
Homeowner Date
• 1 �
t
BRAVIN
Home Services
100 A Kent Farm Road
P.O. Box 682
Hampstead, NH 03841
Sean P Parsons Owner
781-85M285
HOMEOWNER INFORMATION
edf,����ye,(G,- �/l/�� r�ea.rati�i- sG r.�A/� ✓l Gv/i�0 r/�v�
Name j cr�.Aded Jl. 44 e e 1 .tiLQ pL97 a
StreeS61Cr Address(not
f Cxtalo3 City/Town State Zip
Daytime Phone Evening Phone ¢�200 _,
Mailing Address(if different than above)
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Bravin Home Services agrees to do the following work for homeowner.
Qlp�nA r LI ( CVe� S O< t1c�Pr�civ✓
Materials expected to be used
SCHEDULE
The following schedule will be adhered to unless circumstances beyond our control arise.
Homeowner agrees and understands that, due to unforeseen conditions, Bravin Home Services
cannot guarantee a specific date for completion:
P
Work to begin: ///-cl lOs' Expected date of completion:
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Bravin Home Services agrees to perform the work, furnish the material and labor specified above
for the Sum of$
Payments will be made according to the following schedule
dLue upon signing contract
$ by_/_/ or upon completion of
$ due upon completion of contract.
$
A \1 Won't-,. er C-)kVVJ //done
MkVvk.%a\ �a>�$S �l5 st R2/�e�
p2 O5� rtO be �h WopL ZSulo c�»trc�ior�
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t,pur< 22>vte�iihcS wn� eva�1� w�bt. � .. lUwys o6 ���t 1JA
0
CITY OF SALEM� MASSACHUSETTS
< PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
A�'MM6� SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building 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: C `
A)nn4 P-c -sJ- Cr, (4c,5-Q-, (Location of Facility)
�gigydature of Applicant
ll I1 � 1� �
Date
The Commotnvealth OfMassaemusens
Department of Industriall Accidents
Ofce of Inwstigadons
600 Washington SteM
Boston,MA 02111
wwtt+:tnassgoWdle
Workers'Compensation Insurance Affidavit: Bugders/Contrac(Ors/ElecbiaansMui Please Print ��
Applicant Infotvaatio
Name
Address:3�113aS
S
civ/statell Phone -1�51 �SS�S �Sa85
A
reployer'?Cheek the approprls"box: Type of project(re9dred):
pbyc with 4. 0 I am a genasl contrsc or and I 6. New oonstluction
s(till?and/or Part time}• Have?tired the mb ooatra 7. Remodeling
listed on the attached sheet t
le pmpriemr or Parma' These sub-contract on bave S. ❑ Demolition
have no empkryed q„orim, cow• insurance. 9. 0 Building addition
wotiOng fbr me is MY Cal 5. 0 We are a owporation and its 10.0 Electrical repairs or additions
�0 � COS nsarance oa have exercised their1.
regnued j of exemption per MGL l l•0 Plumbi
fficu og repairs or addition
3.0 I am a homeowner doing all workight>
workers' COMP. c: 152,41(4),and we have no 12.0 Roof repairs
inaareace ore"irel t employees. (No workers' 13.0 Other ZIPr.\< (Zle PrA r'
coml insurance:slaved 1.
;Any oeoiPotebeckt box Nlantalsoc§ nut Poe se do sir not and Porn]weaAgde� oliogrir�uWmbn*Isnew' davitindicatingsuch
Housam swcb kdd PotsllWat io�gt�Y dui
:Cwtraclon Pot ctwek dtis box anal ettecbed m edditiood stet sbowieg Poe Haft of Poe mb•cwasdws and Poet avo,ten comR Potkr int'otmet+oa
I aw on entployec t/tet 6 provtdled worUn,eonVensadoe?u w=ee for wy earployees, Below 1s the po?4y utstJob air
iuforma*a
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State
Attach a copy of the worker'compes"doa policy deetaratioa page(showing the policy number and expiration date).
Pare to accare avenge as required
Section 25A of MGL c. 152 can lead to the imposition of criminal Penalties of a
fine up to$1,500.00 aod/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
Investigation of the DIA for inamane coverage verification.
I Jo ksnbycs r flu piles oil nobles of perjury AMA*brfornrodoe provided above Is Vale sad sorre �R c
D dt tb a
#• l
rtj.q:Ol
d ass stilly. Do not writs m Ili eno,to be evo ylik/d by sly or mx'u Ill
Cityr Town: Pernmucenu M
g Authority(circle one):
of Health L Building Department 3.Ckyfrows Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
1111V1 lilNbiVll Nall 111Ab1 1ab61VilA'
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an amployes is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written"
An employes is defined as"an individual,partnership,association,corporation at other legal entity,or any two or rumors
of the foregoing engaged in a joint enimprisei ad including the legal representatives of a deceased employer,or the
receiver or tmsam of an individual,partnership,association or other legal entity,empbymg enVbyccR However then
owner of a dwelling house having not more than three apartments and who rides therein,or the oft of the
dwelling house of another who employs persons tn do mamtesasce, construction or repair wort on sack dwaing house
or an the grounds or building appurtenant thereto shall not license of such employment be deemed to be an engAoyer.-
MGL chapter 152,125C(6)also states that"every state w local Neemtag ageaey shall withhold the isnanee or
renewal Of a license or permit to operate a business or to eondred buildings in the eonu o wealth for my
applicant who has sat produced acceptable evidence of Compliance with the h»nranee coverage required.-
Additionally,MGL chapter 1S2,125CM states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of tiffs chapter have been presented to the contracting antbodty."
Applicants
Please fill out the workers'compensation affidavit completely,by cheddog the boxes that apply to you situation and,if
necessary,supply su oontractnr(s)name(s),address(es)and plane number(s)along with their certificate(a)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(id8)with no employees other than the
members or partners, are not required to carry workers'compensation immisam If an LLC or LLP does have
employees,a policy is requra Be advised that this affidavit may be submitted to the Deparment of rnduadrial
Accidents for confirmation of insurance coverage. Also be sums to sip and date the aflldav1L The affidavit should
be returned to the city or town that the application for die permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Deparlmeat at the number listed below. Self-insured companies should enter their
self-insurance ticem number on the appropriate liat
City or Town txIIdahi
Please be sure that the affidavit is compleu and printed legibly The Department has.provided a space at the bottom
of the affidavit for you to fill out in the went the Office of Investigations has in contact you regarding the applicant
Please be sure to fill in the permidlicemne number which will be used as a reference number. in addition,as applicant .
that must submit multiple pem»tticense applications in any given year,need only submit one affidavit indicating currant
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in
awn}"A copy the affidavit do has been officially stamped or,marked due (�or
EN as proof that a valid affidavit is on file fbture permits or ticessp. A new affidavit most
be filled out.. or town may provided t the
t each
year.Where a home owner or citizen is ob�isg a license or permit not.related to any business or commercial ventm
(ie.a dog license or permit to barn leaves etc.)said paean is NOT required to coaQlete this afSdavk
The Office of Investigations would like 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,tekpbono and fax mmmber
The Commonwealth of Massachusetts
Department of Industnal Accidents
Office of Invet:dgad=
600 Washington street
Bosom, MA 02111
Tel. #617-7274900 ext 4o6 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-21i OS www.mass.gov/dia