284 WASHINGTON ST - BUILDING INSPECTION (3) ck #
IS PMWIV Loomed In
to Hlmeb OIMMON Yak.No _ aall"Us
b P "WIV Loomed In
ar OanmdOn Amn4 Yam_No
SLINAM PER NT APPLICATION POP4
P«mR tw
(Clrola whim aw apply) Roof, Rannof. kOW S ft COnU W D" Shedo Pool.
RipddRapbm 01har•
PLEASE FILL OUT LEOEILY&CONPLETELY TO AVOW DELAYS DL PROCESSM
TO THE INSPECTOR OF BU LDINOS:
The undersOW hereby applaa for a pwM to bold a000dq to 00 falawkV
Ownara Name
Addmaa a Phone -�2;�4 &bfi59JAIP91V 1071 �W— 5-7 6�
Ards ods Name
Aftw a Phone f 1
Aftm a Phone 7i5— 49gsi z),t/ j701 5%
No is va pram.@ it bWWr1p?
MOAdM d kddnp'r r o dwMYq,for how wAw wMin4-.�-
va biadim ,M -M b WA 4
Eansu d mod�6,� Ow Llouur 1 N °` ewd LIOIIIn• G°S D 6 3 4 3 l
s*"nof Apphwt
SIGNED UNDER THE PENALTY
OP PML WIY
DESCRIp M OF WOIJK 70 BE DONE
i
SONKrrAB dG_Uoi o3dw
QEIIM��V
z S 611191 �l
a3lmvw d
�av7A
NOLLVOOI
vv 0��
QL
LOS NOLLV* lddr
/ •O
f`
CITY OF SALEM9 MASSACHUSETTS
♦
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. L190VICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Deaartment
Debris Dismal 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 LveeAly&75 (Location of Facility)
l7U`i'I�ST�JZ "
Signature of Applicant
Date/ —
Departxwnt of Indus&W Accidents
Oglee of lnvesdsadons
doe Wawnros Swd
Boston,MA 02111
xovw�raostsot✓Bi
Worker'Compensation Insurance Afdavit: BuOderslContractoia/Elec ridsns"mmben
ADDUMMIt info MGM Please Print Le:¢ibty
Name
Address: 7/5
city/statd�a� L y N� r✓l� • a����P�one�: 7�/ �9 � -�i��
Arty u employer?Cdak the aP Wi@ft bo= Type d project(required):
1.Q I am a empbya wild 4. Q I am a FWW eopUactor and I 6. Q New conun on
employm(fin and/or pamtunels have hued fie so¢ao s 7. 16 Remodeling
2.)OfI am a sole proprietor or Perna- lisped on ae anscbcd:Leek
$hip andbm no employees Tbese mb-comraaon have S. ❑ Demolition
working forme in am" cap**. workers'aon4-bwomoa 9. ❑ Bmldmg addition.
(ldo woAM, �hwulmov 5. Q We=a ompomdon add is 10.0 Electrical np*s or addition
of om have eaacised then rqahs or Widow3.Q I recli"I
doing all vwrk rW of exemption pa MGL 11.0 Plumbing
» [No aotkeis' wmp a 132,41(4N and we hm no 12.Q Roof repair
inurance ragai ed l t empbyaa (No wodwss 13.Q Other
c-imp,imormce required.].
•Anywp",Wash 1 box rlwMamsnart*Amcdmedowlbowh*ftklmdW war
tH=wwsmvAaM&dtosMM& kbacsftdwYmdaftdworkwdMtms000"wmocmnmotSAM&sww@Mhvitmmcdi W such
tcaofaton mgchak da bone nut ck dued o fd&bond chat dawmt Pow ran of thw atbConft*d=ad dN&w iwa•mrtq.po&y hlrbwinwtla6 .
�t,��� , a Luarnecs e► ns. Itelow b d wpatio wWJob xWe
I a as etttplaya►tbd ISPV -'-'."r"PS COMpeasdla I MY� eY
barnceCo vacyName
Policy#or Self-im.Lic.S EMdmtba Date
Job Site Address City/StatelZ,ip:
Attack a copy tithe workeW.CompaWlon policy declarsdon page(showing the Polley number and a albs tat date).
pyl=to Sc=covaW as required under Section 25A of MGL e. 152 can lead b the imposition of criminal penalties of a
ere Wes s civil m the form of a STOP WORK ORDER and a fine
tine up to S 1,500.00 asd/or one-Yes impriacmmem. . 1>�
of up to$250.00 a day agsion the violasor. Be advised?bat a copy of this staument may be forwsded to the Otgce of
Juvadpdm ofthe DIA for ioanaoce covaage vaillcadon.
I 1p fumby con*atlo the pales dt/ jPWJwY LW fit med thaw b tine and wr►raG
• 7�l - sr`C-�i/�
O,ddriel.an4jt Iat tdf write Ge tbb Bret,b be toarptLad by eld a►aysns a,�ldd
City or Towns Pert�tlLeene/
faming Authority(circle one):
1.Hoard of Beskk L Building Department 3.Ckyfrown Clerk 4.Eleetrtal Ingwdor S.Plumbing Inspector
6.Otder
Contact Pena: Phone#:
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees
Pursuant to this statute6 an emp'*w is definW as"...every person in the service of another any contract oflnlM
__.._.espress err implied,oral otr writoeati" ____ _
An a Mays is defined as"an individual,partnership,associadm6 cogmdoo dr other legal en*or any two or mote
of the foregoing engaged in alomt wterpr;k,and ixbdIDg the legal representatives of a deceased employer,or the
Toccivaor.tmt:e ofa t v. d omherp h whe
owns of a dwelling house having not more rhos three vwune ti and who midu&acik or fht:occopm of tits
dwelling bons:of another who empkrya pas=b do mamtenaooe,construction or repair work oD such dwelling house
or an the gtormds arbmift appurtenant baew shad not because of such employment be deemed to be m employet"
MGL chapter 15Z J25C(6)aha states that"every date or local Yeeo ft agenq shad wkbboM the Issuance or
renewal of a neeiae or permit to operate a business or to construct buddlps In the eommanwaM far ales
appoleanL who but act produced aeeeptAk evldesce of compliance w"the Insurance eeverap required."
Additionally.MCJL doptec 152,12SM stiles"Neil a the commonwaMdt aw my of its political subdivisions shag
cola into,nay cmtracs for the paBummce ofpubtic watt oat acceptable evidence of oomplianee wife Se insurance
rapiremmts of elm-chapu r Dave been presented to the contracting nthasfty"
Appgcm*
Please fill oat the wworliess'compensation dfidsvit completely,by r3eCking the boxes that apply to your sit cation and,if
may,supply sob-oomtraclor(a)mne(sj ad&c*cs)and phone number(s)along wnh tlieq catitjcaoe(s)of
insuraooa.Lirpited liab>7ity Companies(T.I C)or LimiOed Liabrlity Partiaships(I LP)with no employees other dram die
members or palterers,are not required to carry workers' oompessatitm immasoe If an LLC or LLP don have
employees,a policy is regauet Be advised that this affidavit may be submitted to the Department of Industral
Accidents for con&maden of insurance coverage. Abe be sure to sip and data the&Mdavk. The affidavit should
be returned to the city or town that die application far the permit or license is being requested, act the Departraent of
Industrial A=MczsL Should you bavemy questions rig the law or ifyou am required t obmin a workers,
oonip usation policy,picase cad the Department at the mmmba listed below Self-rotund companies should eater their
tW_fn tieememnber on the spptopriaee line.
City or Tow.O idad
Please be sme dirt the affidavit is complete and printed legibly. The Department hes.provided a space at the boom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regaiding'the applicant
Please be sore to fill in the pamiuliceme n®I wbkh will be used as a reference number. In addition;an applicant
that mist submit multiple pamWhcense apphcatiaus in amy given year,need only submit one affidavit indicating ctmrent
policy information(if necessary)and under"Job Site Address"the applicant should write"ad locations in (city or
town}"A copy ofthe affidavit that but been officially stamped ar,nwrl ed by&a,city or town may be provided to the
applicant as proof duo a valid affidavit is on elk for¬e pamib or licemes. new affidavit most be Sated out each
year.Where a bona owner or citizen is obGiaing a license or permit not related to nay business or commercial venue
(i.e.a dog license or permit m burn laves W-)said person is NOT required to couples:this d 5devit
Th:Office of Investigations would lilts to thank you in advance for your cooperation and should you have any gaestiov4
plane do nothaiWa b`give us'a call
The Department's addeas,telephone and tier number:
The Commonwealth of Massachusetts
Department of Industrial Accideft
Office of Iavestlgadom
600 Washington street
Bosom,MA 02111
Tel. #617-7274900 eft 406 or 1-877-MASSAFE
Fax#6 7- -1 727 7749
Revised 5-26-05 www.mass.gov/dia