33 WILLIAMS ST - BUILDING INSPECTION .pWS*W6Z-qEfiL£A+1AG OkPPROVED BY T44E
JWj9IDB Pl' W TDA.PEFLT AMO GRANTED
CITY OF_SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof. Install Siding. Construct Deck. Shed, Pool,
Repair. Other: —1 ,n
PLEASE FILL OUT LEGIBLY&COYPLETEL TY O A OID DEL AYB I NPR
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: c�
Owner's Name � IE rL U� - ly0�1�L
Address & Phom B `S W[1 6. n S �O l . (401) V 2 �c 56 G -5Architect's Name J 0 t) �-- Q V\e&—&Ct 'L0
Address & Phone tab t70-.Kof E' ( am 30 4 - 3G 5 5
Mechanics Name
Address & Phone
Whd into PAPM a Wildlrp?
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Malwial of blYl WV? 0 a dwOft,for tow a my fwn ln?
WN WkkV cwtonn to law? Ambs"?
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r , Signatu
SKiNED U E PENALTY
OF P
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
NO.
APPLICATION FOR
PERMIT TO
LOCATION
33
PERMIT GRANTED
zoos-
APPROVED
TFECTOR OF BUILDINGS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlee of Investigations
600 Washington Street
Boston,MA 02111
www.massgovIdle
mbers
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elep ase Phi LeQibiv
Avylicaut Information r T
Name Mus P°iranm4ndivo"O. {Tt) tY� S)�RAJ tr>��� IQA L1 b tz
Address: i aJ OR1r,J i C�E SC .
..1 r`A t'�. 1 g0
City/StatelZip:� Phone#--rr—
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(kn and/or part-thm)s have hived the sub-contractors 7. Remodeling
listed on the attached shut. t
2.® 1 am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition
ship and have no employees workers' comp.insurance. 9. ❑ Building addition
working for me in any capacity.
[No workers' comp. insurance 5• We an a corporation and its 10.❑ Electrical repairs or additions
officers have exercised they
required.) 11.❑ plumbing rep airs or additions
all work right of exemption per MGL
3.❑ I am bomeowr long c. 152,§1(4),and we have no 12.❑ Roof repairs
myself. [No workea rs comp. lo 'ees. [No workers
insurance )t employees. 13.E] Other
comp. instance required.].
Any applicant that checks box#1 most also fill out the section below showing then worker'convennnon policy iuformeryon;
?Homeowners who submit this dri&vit m&cathrg they sat doing an work and then him outside connectors must subrttit a new affidavit indicating sock
tConlrecbrs that cheek aria box moat attached an additional sheet showing the same of the antrcontractors and then works camp.policy mfor roation.
law an employer that is providing workers'compensation Insurance for my employee& Below it the policy and fob site
information.
Insurance Company Name:
Policy#or Self-its.Lic. #:
Expiration Date:
Job Site Address: City/State/Lip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Palmier to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/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
Investigations of the DIA for insurance coverage veref"dOn.
I do herby ere and penabies of perjury that the information provided b and correct
D : ' D �ooS
n M
rAo6orlty
Do not write In this area,to be completed by cloy sir town oo7clal
Town: PermM/IAcense#
(circle one):
2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone#:
.11liVa nnafin.aVaa "&A" JLAAO&A aaT 11A%FJ.l►7
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 liar,
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 a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or.trustee of an indivirhtai,partnership,association or other legal entity,employing employers However the
owner of a dwelling house having not more than three apartrnems 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 in 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"Neitba 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-contractor(s)name(sl addresses)and phone number(s)along with then catificate(s)of
insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships UY)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required: Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the atRdaviL 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. Self-insured companies should enter their
self-insurance license number on dic app 2&te lira
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 fill in the panA/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pamittlicense 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 fined out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial vermin
(i.a a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
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,telephone and fax rumba:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlee of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised s-26 Os www-mass.gov/dia
71.
Board of Building Regulations and Standards License Or registration valid for fudividul use only
HOME IM OVEMENT COURACTOR 7 before the expiration date. If found return to: I
Regh&Va406VV\.— _ Board of HoOding,Regulations and Standards
One Ashburton Place Rm 1301 k
h Wzoo? #: _ Boston,lMa:02108
JOSE PONCEER/lZO a
JOSE PONCEERA�Zo0�3N
65 JOHNSON ST#1 _-
LYNN,MA 07902 Administrator t id without signature ��
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildin¢ 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 111, S 150 A.
Th debris will be disposed of in:
fl l (Location of Facility)
Signat scant
Q ) 2- ri 5
Date