118 WASHINGTON ST - BUILDING INSPECTION (11) Permit Numbera�
APPLICATION FOR PERMIT TO ERECT A SIE -CEIVED
PERMIT MUST BE OBTAINED BEFORE SIGN IS FABRICATED AND'NSTALL&P 1 7 2007
Is
Location,ownership and Detail Must be Correct,Complete,and Legible DEPT.OF PLANNING&
COMMUNITY DEVELOPMENT
City of SAI.EK MASSACHMETis
TO THE BUILDING INSPECTOR•
The undersi toed hereby applies;for a permit to�J—Erect Alter Repair assign on the following described buildings:
Location and No. I I p `ICJIC �A 3 kt.. 54 Zoning/District
Name of Property Owner 1 'C G y `
Ih`, eyc.C, &r,1&,L\4( Address A �}
Name of Sign Owner (( `
If Owner is a corporate body,name of responsible officer t C� Qy k sk<\hT
Name of Licensed Sign Errector ` t�`Y G't 5�• Salem License No.
Address VN fo QU tAVrC� Sys &oa (;,c I ilk %\
Use of Building: 1"Floor (Q7TAJ 9 ^'� Yd Floor
Zed Floor, 4-Floor
Frontage: Building
linear ft Property linear ft
Type of Sign Proposed: [�(Surtface ❑ Right Angles to Building ❑ FreeStanding ❑ Awning
❑ other
((s�pecify) II C(
{ Proposed Sign Materials S ��^K l 1 $ 44 c ` ` O o 2
fProposed Sign Dimensions �' y Sign Area --ft
Existing Signs: Surface: Sign Area s9 ft
Right fin: Sign Area sq ft
Free Standing: Sign Area sq It
Other. Sign Area sq ft
Signs to be Removed- Type Sign Aura sq ft
Signature of Owner
•Ardtoriaed entative
Signature of Owner' Rcpres
Estimated Cost of Net Work A /► �,�e
to Address J�p� r J`
$ t bL Telephone
Signature of Property Owner C'(00Ve -
APPROVALS(Department Use Only):
G&COanuuNriv Di;vm oPeffitar HISTORICAL CopaussioN B ING IIVgp6CfOH
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
w IRAs R[F.Y DRIXa1LL
M. .%Voit I=WAu u:%crOle$TxELT 4 SALEm.MASsAciu.Xt.,,*es019r �
TtiL•978-743.9595 0 FAX:9711-740•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Le ibl
NaMC l8ua%inw.WOrganintion/Individuall: i
)CAK
Address: \ „-� - /
City/State/Zip ON`A ` Phone 0:
Are,you an employer?Check the appropriate box: Type of project(required):
I1.❑ 1 ant a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tine).• have hired the sub-contractors
1 a listed on the attached sheet. : 7., Remodeling
m a sole proprietor or partner-P P
n ship and have no em These sub-coployees tractors have 8. ❑ Demolition
workin for me in an capacity. workers'comp. insurance.
8 Y9. ❑ Building addition
iltn workers'comp. insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
rcquireJ.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myselL(No workers' comp. c. 152,¢1(4),and we have no 12.❑ Roof repairs
insurance required.] I employees. [No workers' l3.❑ Other
comp. insurance required.]
1
•n,ry appliGua that clwcW boa nl marl also till wa that scctiao uciuw showing thvtit wwksri companaWial policy infutmatilaa.
'1 Wavulwttar who submit this affidavit indicting I"am doing as work and then hits outside contractor mall oulnnil a new amdavit indialing such.
�c ontr%iu ni Thal chaste this bur muse attached an additional.heel dwwing the name of the subcontrwton and their wurkan'tamp.policy informarion.
/con an employer that Is providing workers'compensdon hhsarance jar my employees Below is the policy and Job site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic. #: __. . __.._ Expiration Date:
r
Job Site Address: City/State/zip:
.\track a copy,of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to sucure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
tine tip m S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tip in 51_50.00 day against the viol to . k advised that a copy of this statement may be forwarded to the Office of
In\Yilhanons o t DIA for iosuranc cover' "; YCtl tleallen.
/do hereby certify w r the par s UPI eno/N s of perjury that t/re iajurmatlon provided a ve is u e and coned
Oric ial use only. Do net write in this area,to be runlpleted by city or tow=Plumbing
City or Town: _-. Permit/Licens
Issuing Authority (circle one):
1. hoard of health 2. Building Department 3.Cityfrotsn Clerk 4. Ele6.Other
Contact Pcrson: Phone
s
Information and-Iristructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral ar written"
Ain employer is defined as"an individual,partnership.assmiatim,corporation or other legal entity,or any two"MOM
of the foregoing engaged in a joint 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.§25C(6)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 Is the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally.MGL chapter 152,§25C(7)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 this chapter have been presented to the contracting authority."
Applicants -
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If as LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe 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 resumed 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. Self-insured companies should enter their
self-insurance license number on the a ro bate line.
City or Town Officials
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 till in the permtit/license number which will be used as a reference number. In addition,an applicant
that must subunit multiple pertmitilicense 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 marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Otliec of lnvestigations 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 Dcparnnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of[nvestipdong
600 Washington Street
Boston, MA 02111
Tel. ti 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05 www.mass.gov/dia