16 WILLOW AVE - BUILDING INSPECTION (2) � eE+ass+wa ArPRovfEo aY ZiiE
ANUUM MOB TV A.P>rE"fItiEINIII QRANTkD
CITY OF SALEM
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• 10GWOWASM ARM . YM No
Pafintt to: PERMITR;
BURaM APPLWATM FOR
(Ckcls whM war apply) Roof. Ramd, InMall Skft Cw jM Dsolr, ShWd, ppci,
RWRWRsplaoa, ovwr: a w Van and
KUM PILL OWT L MLY i COMPLETELY TO AVOID DELAYS M PROCUUIp
TO THE 148PECTOR OF BUILDINGS:The WdWWWwd '.
hw* applin for a pwmk to build accord ft to the % oft
O~s Name K i rl l L,
Address a Phorw
Ard+bWs Nanw
A*hu a Phorr f t
Maolwnica Nam. ece�y Clas�
Address a Phorw SGop_rvte c5k . rg18� 9'�3 149
"m left P0Pa0 of Ou1dMg7 MSiC, A4 ,
MIN" W 60c\ N a dwMi g ow how mw lmonl
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tatrawd a M ZQ,to My UMM• era LbM•
a.. L*tewwat
Lta. / 14 3 1 s.
rid m of Applowit
sea=summ inTHE PENALTY
OF PWLRMV
DESCRIPTION OF WORK TO BE DONE I p l -
5�r p \n0ccx, Vla, �Ck6 't (A P'y �Iv2 fa� �l iCl
R�NUU �Ti � ru
MAIL PtEffi11T TOt
APPLICATION FOR
PERI/T TO .
�/� �fll,ef
LOCATION
/6 6illIll i �vG
PERQAIT GRANTED
200&
1 ECTOR O48tAlMMl-
f
CITY OF 3ALMM, MASSACHUStiTTS
PUNUC PROPEM DCPAMWENT
(20 V"HINMN &MKW, 340 FLWR
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ht. (976)7411-YaYi tn. 300
FAX (8710 740-""
STANUM A rUsavim Jt4
MA
DISPOSAL OF DEBRIS AFMAVU
I.sooa Imp - WA tbs P9OV =of MM a 4k S34 I aelmMlOgs tilt m a canditim
Of Btsildioi Pstmit r .m dsbrft rwoft be dwcmdmcdm ad fry
pwmad by die DwlftPamftAd be digwd offs a ptopaly Ueamed solid-vtsts
dispud& t 1,ss ds&M by MM a DL SISK
Zb debit w�1 bs disposed ofst _ ��e.n �cAn��,r
LocodmofF ddity
Ip 20 s of Permit Applicmt Data
FULLY camplata tit"swim mhm,dkft
MAMB PRIIPP CLLaLY)
_-�Tos,e2M4 CIaA
Nsme of Pashit AppHod
Firs N ulk if ssq
9 A o .
A"lle.ry�SW@
MW elbow,louts re um tiers debris Atom tit damobaM rmov&W%rehab or osier
at dew or sftca=M(g. bf� W 1°a�Y-Heum ed so"wme disposal
by cnX SI SOA, and the buildup permits or lice"an to
=gem tit bew s of tit salty.
uepannsem of inausrnat Aeciaents
Office of lttvestlgadons
600 Washington Sdeet
Bostors,MA 02111
tvWMMas,gos✓dia
Workers'Compensation Insurance Affidavit: BuHders/Contradors/Elechidans Mnmbers
Applicant Information Please print Leeibiv
Name ��r1�
Atkhesa• 0'�3 3 SaaaMy�. 5k -
City/State2ip: 5• �ar+'•��� M, A _ Phone# q1-6 9H 3 I Nek
An you an emplayer't Check the appropriate bow Type of Project(required):
I. I am a employer with 4. (] I am a pewd oontruinr and I
byea(fan and/or part-time}' have hived the sub-conmickm 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet: 7 ® Remodeling
ship and have no employees These sub-contractors have S. [] Demolition
Working fhr me in any capacity. workers'comp.insurance 1 9. 0 BuildinB addition
[No waken'comp.insurance 5. We are a corporation add its 10. Electrical
officers have exercised their repairs or addition
3.0 I am a homeowner doing all work rWA of exemption per MGL 11.0 Phmibiog repairs or additions
myself_[No waken' comp, a 15Z 41(41 and we have no 12.0 Roof repairs
immance rag rir°d]f embYacs. V40workent 13.0 Other
Camp.insurance required]
•Any epplit a that chub box MI rout 40 fill out the secdoa below ohovina nstr wars'compoon6a policy mfwmatlos
t Homeowness who mhmtt Us affidavit adicaftes they an dome all wok cod thin bee outsde mahaetas meet subuth a new affidavit iomcatina task
tCwtraebn to check this box one anaded m ed tional shad abown*the noon of the subcoohse0on end their wovtW cane ray hdornnsios
I am ere employer that it provldlxS workers'eompemadas buurmee fa my eaployees. Blow b Mope& and Job sib
Jwjort�artoa.
Inalaance Company Name:
Policy#or Self-ins.Lic. N: Expiration Date:
Job Site Address: City/Stwcg4:
Attach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Faille to scare coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 1
fore rap to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in lbe form of a STOP WORK ORDER and a fine
of up to$250.00 a day spinal the violator. Be advised that a copy of this statement may be forwarded tn the Office of
Investigations of the DIA for insurance coverage vaification.
I As kerebyeon*under Ji l w andpeaalda ofpeywy that the btferaradon prov[dad 6 sae and Correa
D r; �6 ao06
Phone N.
Offleid use only. Do edr wrW br tklr area,to be completed by CBy err rower odleld
City or Town: PermWLieeme 0
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Clty/Powa Clerk 4.Electrical inspector 5.pl
6.Other umbing IInspector
Contact Peron: phone N•
Massachusetts General Laws chapter 152 requires all employers to provide wodras'compensation for then i x
Format m this statute, an rarploya is garland as"...every person in the service of another under any contracct t o offire,h
express or implied,oral or written."
An employer is defined as"an individual,partnashfp,asaoaat^Corporation or other legal entity,or PY two CIT morel
m a joint and including die legal representatives of a deceased employes,or the
of the fo wimg engaged anocianon or other legal entity,empbying employem However the
rcceiva or troolve of so individual,p * anal who therein,m alit otxsipaat of dw
owner of a dweltmg house having act more ihsu thra r Tepairwo*on such dwelling home
dwelling house of mother who employs persons a do msiateaance,Construction or on be deemad to be ineropbya."
or the building thereto shall not bemuse of each empbymat
grounder or buding app
MGL cbmW 152,125C(6)also states that"every state or load"ceasing sgeney du&wkhrold the issuance or
rmewad of a lkem or pantk to operate a badaess or to eoirtraet buildings Is the eommoaweahh for ny
applicant who has not produced acceptable evidence of eomp8anee whk he imr n& �
my Of its political sadivisions
Additionally,MGL chapter 15�,4ua71 sonofpubhe wort nnp7"Neither the Co acceptable evidence of compliance wa the ban==
enter into any contract Sir the paftwom
aaquuements of this chapta have beta presented to the contracting sutbotriy"
Applicants
Please fill out the women'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sob-cons SCICKs)uaote(s),add>en(ce)and phone mrmba(s)along with their ceatifiate(s)of
insurance. L nited L AW*Companies(�or Limited Liability parmerships W)with no employees other thin the
�m cry workere compensation limmoce. If an LLC or U2 does have
mcnibe or parsons, an
not MM advised that this affidavit may be submitted todo
the Department of Inseal
employ
ri
txa,a policy is required Be
coverage, Also Also be su to sip and date the aflldnvk. t
be tetumed to the city or town honld
Accidents Sir o�rmatron of imsmsuceOf
that the application for the permit or lioense is being tequeated,
� „ld you have soy ynestiont regarding the law or ff you are required a obtain a workers''
,p sup the a<the nuauber listed below. Self-ins red con"nag should enter they
compensatiouPoftself-insurance license no"on the ima
Cky or Town Oflldad
Complete ad printed legibly. The Department has provided a space at the bottom
Please be sin that the affidavit's bat to contact you mipirding*0
' of the affidavit for You in ffi out ID the eve which,will be used asflice ofs a reference number. In addition,an applicant
Please be are m fill rit/�
in the pame m any lien year,need only submit one affidavit indicating current
that must submit multiple pamioicense applications
policy information(if necessary)and under"Job Site Address"the applicant should write"all location in (caY or
town)-A copy Of die afildavit that has been otlicially stamped or marred by the city or town may be provided m the
j applicant as proof that a valid affidavit is on file for future Peroms or licenses. Anew affidavit most be filled oat each
year.When a home owner W citaen is obtaining a license or permit not related toany business or commercial venture
(Le. a dog license or permit to boa leaves etc.)said pawn is NOT required to complete this affidavit
The Office of Investigations would lire to thank you in advance for your cooperation and should you have any questions,
please do act hesitate 10 give us a call.
The DcprrtmeuYs address,telephone and far mmnb W
The Colnlnonwealth of Massachusetts
Department of Industrial Accidents
Office Of Investigations
600 Washington Street
Boston,MA 021 It
TeL # 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwmim.gov/dia