77 WILLSON RD - BUILDING INSPECTION r
4LaMBiAtl��EfRA94#0 APPROVED Sy RE
lwawx=PWR ZDAPBAWABM GRAN=
CITY OF_SALEM
oar
to"' OWial9� 01 YM�b ✓ 2 pF�ic �I�AI(G/�S
Q SALES HiG)t
is�noa AMR? Ysk�No Loomod in ✓ ScHdp�
BINLOW PBRWT APPLICATION FM'
Permk to:
(Orcie wtliotwwr apply) Roof. pAwd, IwAN SWft Cofwtfuot Dook. Shed, POOL.
RspsldRsppl 00W. ?L&cE 1 Tekk?tkARY *fiCC ' QUl s
PLEASE RLL OUT LE+t KY i COMPLETELY TO AVOID DELAYS W PROCEBBMIG
TO THE INSPECTOR OF BUILDINGS:
Ttw urfdaraprwd hereby OX" for a pfrfrnit to build aoowft to tlw to ft"
Ow mes Name G14ANE 6vt L_M ►J G CbMPA N`I
pRoV�f�Fuc,� � Ql 61�03
Address& Phorw JkV,5oN WA(_kWA`( r y el ) vs 6 S6em
Afd*eWs Nam*
Addrom A Phan* L 1
Mochanics Name -
AddMu & Pharw ( 1
wrw is ftw papom a ? �eM PuM tiY p F F I 't'kA l c,e k f
VAWW a OuYdMp4 M a dirwY g,for how awry tomin?
Maf Mom cordon to low? ry E S AWWU? N O
Eel oor 30 W fWa ply Lioww r NIP- am Uoww r
Sb. &= Imptawmmt ,
Si &Wm of Applicaiint
8W= UNDER THE PENALTY
OF PwUURY
DESCRIPTION OF WORK TO BE DONE
SFZ UP Two T67AAPralAfi`I �3194s ±� OFF1 <.,r,- TkAI(_,rRS
RECATcyE to TWA NASE-b RMoyaT lnN OF SALM Rt&H 56H L
c0NI- TRAIL*L lS 121x b®�
MA L PEMT TO'
No.
APPLICATION FOR
PERNNT TO
{6� (fdlg s y'ZV C.77&A/ o F c e.s
LOCATION
77 CJi./��4ono 2�
PERMIT GRANTED
R OF B LDNGS
The Commonwealth of Massachuseft
Department of Industrial Accidents
office of Invesdgations
600 Washington Street
Boston,MA 02111
trcorEIe asstwwN.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Con Pp Legibly
Applicant Information
Name "A toy pU I L(1�
Address: 'SA cKStN WAcVWA
City/StatelZip: �Ro�V 1 D�U c ,� Phone#: 61 V S b- 8 06
r2.
you as employer?Check the appropriate box: Type of proles(required):
I am ilemployer with 4. ❑ I am a general contractor and I 6. n New construction
s have hired the sub-contractors I am aemploysole proprietor oees(M and/or r artnerart-time, listed on 1Lc attached sheet t 7. ❑ Remodeling
These sub-contractors have S. ❑ Demolition
ship and have no emploYM workers' comp.insurance. g. Budding addition
working forme in any capacity.
[No workers' comp.insurance 5. ❑ We area corporation and its lo.(] Electrical repairs or additions
officers have exercised then or additions
11.❑ PlumbiuB repairs
3.El am a homeowner doing all work right of exemption per MGL
c. 152,§1(4),and we have no 12.E] Roof repairs
myself. [No workeis camp. to ees. '
insurance required.]t � Y [No workers comp. 13.� Other L Ici
insurance required.].
Any applicant that cbecb lhi i!1 meat M fill out the doeion s an wale end ffieo Tine oW�C contractors must be"n a new effidsvit bAc sting such
i Homeowner who atbmil rids af6da"it indicdittg�eY calls of the aubmotteAon end they worlcen'comp•policy btformetiom
tConvw ma that check ibis box must attached an addMonal sheet ahDWMg
the I am an employer that is providing workers'compensation insurance for my employees Below it the polky and fob she
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #:
Expiration Date:
Job Site Address: City/Statelzip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Fail=to segue 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 mlprLwmnmt,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 verifw2tioa. ,
I der hereby c(e�rdfy under the palm and penahies of pedury that the Information provided aboAve b true and correct
Date• ' ii 0 V5Pho —
n #: 01 cecc
rum , Do eat write/r this area,to be eompkmd by sky or town o,�4sialPermN/l.icenaeity(circle one):lth 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone#•
11alVl lilfi iaVal fills ila0 is ll�r a.aVi1D
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employeesr
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 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 individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house laving 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 in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, 425C(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 die 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-contractot(s)name(s),address(es)and phone mumber(s)along with their certificate(s)of
Liability Companies or Limited Liability insuraoa. Limited uluty mp (LLC) minty Partnerships(LLP)with>m 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 alga and date the affidavit. Ile 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 raptfred 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 appropriate line.
City or Town Of&Wa
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 permit/ticense number which will be used as a reference number. In addition,an applicant
that rust subunit multiple permit/license applications in any given year,need only subunit 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 mast be filled 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 in complete this affidavit
The Office of Investigations would lice 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 number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617=727-7749
Revised 5-2ti os www.mass.gov/dia