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0080 WASHINGTON SQUARE EAST - BPA-05-642 -PL9M-MOST-BE fILf� APPROVED By T*IE U�S,p JpA .PWR TD A PERMIT B,EWG GRANTED CITY OF SALEM �No. Date Is Property Located in / Locatiou of Q the Historic District? Yes_No V / Building Is Property Located in / the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof R Install Siding, Construct Deck, Shed, Pool, epa eplace Other: ( 10 r3<k&-o,\ PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name C�S (i�C' ��� ( Ty ro S T Address & Phone w�sl1�^5 7c� SCE (9?g ) ? LI LI- Z 3 CO Architect's Name Address & Phone j ) Mechanics Name 4 Address & Phone n ( ) What Is the purpose of building? Material of buiiding? w°"Q If a dwelling, for how many families? WIII building conform to law? Y&5 Asbestos? d10 a Estimated cosA9o,o0o City Licensers N A� State ©�7Sz Bome Improvement I�/.1�� 7 Lic• 1 1413d KL— �� 3 Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DnnONE r��_C',''`WI,C�' �C.�rO�Dna tl5v:�� /�Gw �u,I hCt7ur ��lwS��:lS (7 r>Gij r1,g r73c. 1 con ( 6 ( RGJ)aco- Co-, )`A-j {' F la'rv' g , Re Myda( R& flow P4;�T �I� J'n�e�Jor wcN (•. MAIL PERMIT TO: 1�vj.- C O T-r 5 r (:bc� y ' 0060 iA APPLICATION FOR PERMIT TO OCATION PERMIT GRANTED APPROVED INSPECTOR OF BUILDINGS ruwx rworum osM�Mp� ao OWW Mw s�r�ow wsww►o�� T66 ►WMo�des.sus sTAM,IN u�sVMs w., - -- . t . • rsro�►t aww��w� • 5 we�aw.l�d.,...Wwdf/oL.Asti .�.e.�}rt.....ii. • 4�■i#�riiii1Sr11R..3R • �.�.11wywt.tr ��� • QT � (�go�(� r1� . 1 jo/o y rr • Riaw�rcza�w.» r ��`PI'To� Ca�SGf �lc J ed� SCsf �fcG�S K� C�� coTT 7�.irw.ewtia��rt aidrlas rdwoflto��w�eiir.r.�s aM�■.�I�di.A�i s ilaw M�pw/L. ins reel by M i A `MA a/r p�aii arllew�w4 The Commonwealth of Massachusetts Department of Industrial Accidents Otrice et inivestigadvas 600 Washington Street, 7`h Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: Buildin lumbin Electrical Contractors Ar'�`lc utinform hon. n-_ °� �-� �:�Pleas PRINTI ih �r name: Ce151iti& (`O'erITy FfLi address: go wczs1 ,,^s T.Vn 5Q city ! 4(0,AIX state: M5 zip OLr120 phone# (M- ?4t- 23S0 work site location(full address): 5-; . C, ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole ro rietor and have no one workin in an ca aci[ . ❑ Buildin Addition kuqu LOX am an employer providing workers' compensation for my employees working on this job company name: T-L)`n C-o Sht t!_c...r lU� address: F,,A e e.O.T 1 citv: -L CLa i PA Cr 0L,%0 _. t11b , '32- $ $0$ g ,a phone#' insuranceeo At Oal)a yw '(Uc. olic # �[f 5 00 0,z.'713q ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone# �, z insurance co. company name: - add _ h city: - . ohone insuranee co. tic # + • 3 w 's 'A+ ttaC6.addipnal 'i n . ro .: , ....-.«r r.y, .r l:w Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. I do hereby tifyIu d the pains a ndfp�ernalti��es((of perjury that the information provided above is true and correct. Signature UPjM hJ-t ov\ Ca.,, 51ruGIIr.\, Date t ( t310r Print name V""IV� u�tp Phone# �;"32- ,5gU6 official use only do not write in this area to be completed by city or town official city or town: permit/license q ❑Building Department El Licensing Board ❑check if immediate response is required ❑Selectmen's Once ❑Health Department contact person: phone p; ❑Other 11,.1 d Sep.20011 r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the`law",an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another 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 employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, 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 this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure 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 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 Department at the number listed below. , ` .., rN .tom, ..y rt ifs•:. .. �;._..: City or Towns 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 Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. Ell w; :Ilgig The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7fh Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406