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30 WHALERS LN - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT vet\laT'RI[Y nRle[.YM-1 7fLtrese Im W&*&%cast $" r a Shalt,kft+ateei a urns 0197p ThL•97t♦.74S."" a F.sx:9M7e0.9#e6 Workers' Compensadem Insurance AflMdavit: Builders/Contncton/ElectrieianypMmben .Annlleaat Information Please Print Letibw Varna lliuvrnst/Orpai:atiaNlm4vupd): �nl _ Adatess- 1030 O63Mlg Lr Cily/stavZip: n6d ulP.R - /YV9 Are you an empbyw9 Check the appropriate boo ,�.�� F[3Ncw (regtalrM): 1.1_J t am a empbyar with.�_ 4. 0 I am a yenmal eowrxtor and 1 ��erspluyf.0(full aruYur pastime).• have hits!the sub-comractora2.❑ 1 am a sob proprietor or partner• lined oil the atteehed sheet I as ship and have no employaea Them wC•eonaaaaes haw onwonting for mein any capacity. workers'comp. insurance. addition (I�n workers'compinsurance S. ❑ We aro a corporation and its squired] Offic a have exekcis !0.p!their ❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions myselL(No workers'comp. C. 152.#1(4).and we have no 12.0 Roof repairs insurance required.)► employees.Leo workers' comp insurance sgttirod) 13.0 Other Ank+vPk the ettccita boa aI men also ah w the sech"bciew rboorioa their warkrea'uompansatire pulity inarrnouiwt, liuesmiware who cubind ilia arlldwit indkwing 9"ree&*6 is wtrl and Mm hire ma"cerelanors man aumdi a nwr atRJavir india,iioa wah. -C t taaen that chat ilia bea mfae aireelard as addiibrl.laws rowing the saw of the Sobptooraostoo ad flair wwkaa'comp.Policy 06mo ilae. /uer an earp6jw that Is providing workers'eampemsadoa hrruraaca jot ray earployeet Bdow/s the pM//e�aad/ob a/fa ._.......»., ir�ararWfuYa..,.,r......�.....w......w �,,..w...usesw...,...:,.,,1....,.Yves.: .,.,...��..�.,....:.... .,,.d�,.y��,..-.-'.,�w.N.... ._ Insurance Company Name:_ ^/ /' _ ._ r'Vl-u-rj _0 S [� t Policy r or Sclf-ins. Lie.tt:_I C 703 4(JQ _ _ Eapirruon Date: Io,.3 Job Site Address: 30 Unia s LA . City1StaLvZip:_fA/A'IA M/9- 01f7,0 Attach a copy of the workers'compensation ptdlcy declaration page(showing the Polley number and expirarlus date). I'ailurc W wcum coverage as required under Scclion 21A u1'.1GL c. 152 can lead to the imposition of criminal penalties of s rift.up to S1.500.00 and/or one-year imprisonment,as wcll as civil ifcnaltisar in the form of a STOP WORK ORDER and a fine of up In S250.00 a Jay against file viOlawr. lie advised Mara COPY of this etalLment may be forwarded to the Office of Inc„ngaumns of oho DIA ror insurance Coverage verification. /do hereby certify undo s and au/ s u/per/ury that the iajareaN&A provided above is true Mild correeL Date .T rls n:e a: U/flriad wee uu/)t /b wW wr/ii/a th/t area,to be rosrpkletd by eay or fawn o//7r/ai City or`rown: Permit/Lkease g Imulag Aulburily (circle one): -- I. ISoard of 11ea1th I. Building Department 3. City/fowo Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other C,.ulact rcrson: _ Phone p: Information- and Instructions ,%lassachusetts General Laws chapter 152 requires all employers to provide workeri compensation for their empla pursuant to this%,am*.an fw,pbjtee is defined as`...every person in the service of another under any eapress or implied.oral or written.` tutodaoa�Corporation a other In*entity.at any two or molt o f he joej oiia engage di`as io�vi igir P � ape k representatives of a deceased employer.a the of the tbregmea engaged iitivsd tit parse rsb age including a get cWe However the association a oiber legal CacitY.employing ermpt0Y receiver or tsustee of se utd►vtdual,act timedP. and wbn resides dictate.or the oaupnt of the owner of a dwal6nt how bwimt sot seas thss ids aptruntentt or re work on such dwelling house house of another who employs persons in do maintenance.nhosathcuoa deem"to be an employs." dwelling gseses don asu bantams of such employment be or on the grounds a baildins appurtenant iviGL Chapter 152.42W(6)�o Miss that"&very slap a legal Ikaasiat steaty drat withhold till Isattesee or q opera"a bandages at as construct buildings Is ttte romateswesM[tie any resewd of a Ikeetre a pertslr with the insurance coverage requtrd."shall appilica seed aaoptabla avtda�®of eosptlsneo wM hers slat prod Grits Beal subdivisions is tierPoh autmttY.MOL chapter 1 sit,425C(7)stall'Neither the eotnntonweal snY enter into any contract fa the perfacuu mce of public work until acceptable evideam of compliance w itb tha inwroxg requirements of this chapter have base presented to the contracting autbortty.` Applieasts vtt completely.by Checking the boxes that apply w your situation and-if Please till out the workers' compensation&Pfidt sub.cotmacwr(s)name(&),address(es)and pboae number(s)along with their certificate(s)of necessary.supply LLP)with no employees adwr than rho Banc Limited Liability Companies(LLCy a Limited Liability (if an LLC or LLP does have members or partners6 am ant required to carry waiters'Compensation bat employees,a policy is required. as advised disk this affidavit may be submitted to the Department of Industrial P. Also be sure to sign and date the aMdaviL The affidavit should Accidents Pa comgmtation of insurance cover" be be retuned to the city or town that the application for the permit of license is being requested not the Department of industrial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers' compensuion policy.please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the line. City or Town Officials _ __.. set has provided a e at the bomm.,w..... please be.sure that the affidavit is complcte and prmted'li giblp."The t>eparatt Pr +Pa _ of the affidavit for you to fill out in the event the Offiea of investigations has to contact you regarding the appl' lrcant Please be sure to till in the purmiulkcnse number which will be used as a reference number. In addition,ao aPD that In submit multiple parmitilicense applications in any given year,need only submit one affidavit indicating current polity information(if necessary)and undo[ Job Site Address"the applicant should write"all lucations in__(city of town!."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to Elie lid at'fidsvit is on file for Haute permits or licensee. A now affidavit must be filled Out each applicant es proof that a va year. Where a home owner a c. . is obtaining a license or permit not related to any busiaess a commercial venture t i.e.a dog license or permit to burn leaves eta.)said person is NOT required to complete this affidavit. fha Ofti:c of Investigations would lace ho thank you in advance far your cooperation and should you have any questions plcase do not hesitate to give us a call. The Department's address, telephone and fax number The Commonwealth of Massachusetts DepaM91111t of Industfial Accidents 06ke of lwesdiat tie 600 WUN11gton Street et>soon, MA 02111 Tel. / 617-727.4900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 ze�i>ej s-26-05 www.masx.gov/din CPrY OF SALEM - - - - PUBLIC PROPRERTY DEPARTMENT r.vstrt■r'�a�tL Ttit:vwaam•F-%a9ttiJ�6sW Construction Debris Disposaf Atndsvit (requual fat all demolition and zdamstial wont) In monlence with the sbtdt edition otdw State Building Cads[DSO CUR socdom 1l 1.5 Debris.sad the provisions o(MOL a 40.S 549 gwldlq Pon N _ is issued with dw condition dmt the debris[Culling ftW this wart shall be disposed of in a ptvparly licensed waste disposal fheility as defined by.%(GL e 111.g 15" The debris will be wann'ssported by: �q I-- �1 rho ckbris Kill be disposed Orin : t�t�un•ra.d,ty) �..p:ra,t.,�r r•.:a.tyt ,.ate e ,.� �fzP. �am ,�• ,o��.�%�.aysar�iu,�P.� . Board of Building Reoulafions and Standards One Ashburton Place - Room 1301 __Boston. Massachusetts 02108 Home improvement Contractor Registration Registration: i00654 Type: Individual Expiration: 6/22/2008 IRA G. MALKIN Ira Malkin 180 Dayton St Danvers, MA 01923 1pdale Address and relnrn card. Mark re:non liv rh:u 'i Address i , Itellewal 1'.11lllhll•litem LuH ....c„ G •n�M 1inna rcni,ml 9Xe Board of Building Regula ons and Standards One Ashburton Place - Room 1301 Boston. Mass?.LGhusetts 02108 Construction Supervisor License .% License CS: 20014 Restriction: 00 I , F Binhdate: 7/31/1955 i a Expiration: 7/31/2009 Tr# 15631 IRA G MALKIN --- 180 DAYTON ST r 3 DANVERS, MA 01923 " — -- — — Update Address and return card.Mark reason for change. !__I Address %-� Renewal r] Lost Card OPS-CAI 4 50M-05/ 1`08490 - - 72t6 TJommeM{<//Oo�'�� _Q�/�.addnc�UdelQ Board of Building Regulations and Standards Construction Supervisor License Licel se,. CS 20014 BSI-ISNdaTo'-71?1/1955 ir& 7/31 M009 Tr# 15631 w t : IRAG MALKIN ,�`,, ,•,�,�_ �, 180 CA YT I N ST DANVERS,MA 01923 - Commissioner r t %EP PDTMEI�IT KPNO.aYCOYl " MAWS 13D WAwDNGTM slum•IMA MAMACMUrU 61l70 A_pPLCATION FOR TSZ REFA_M I MOVA'TIAN cnNCTQi CnON_ DLKOLMOM OR CRANCZ OF UtSZ OR aTrxG �.o�IwroRw►now Loeadan Na"M Buildkt� -- __ -- Properly b beabd h a;Corwnatlon Ares YM Hbarb Dim"YM 2.0 OWNERSHIP INFORMATION 2J Owner of Land _ Name — agar.... go Ta whow. 9-) — —71-141 FApproxknaw MPLIM THIS SECTION FOR WORK IN muX MQ BUILDINOS ONLY Usting tion Number of Stories Renovated in Use New Demolition ExlsOV mate year of Area per floor (st) Renovatedtlon or ronovation ng building New scription of Proposed Work- S/�cli�5rRw- u✓)-c- CPlAY6eS ---—- ---Mail Permit to: What is the cnunnt use of the Budding? 1 Mft? tAatsrlal d Butidkng4 bW e© > It dwo Wg.harr^tiny We toadk*q Cwdbnn te t aw? Asbsstos9 s�o Arctftde t Address and Phorni madw ies Marne Address and Phones HIC Repatratbrn B Cart ucdon Supevbms License B pa mrS FOR Calcule fon Eswmabd Cost / Estimated Coat X STIS1000 PAekWM pwvrA Fate S Estimated Cast X:41J:1 OOG CananMcla�--—An Additional S&oO is added se an Adminw rative ahsrge. Make sun dud ao flown are propsriy and isow written to avoid delays in procesdnp. The undersigned does hereby apply ftw a Budding Permit to bu; •above stated spseftoom Signed under pena ft Of Psdun f,, _ Date o�U J