8 WINTER ST - BUILDING INSPECTION APPLICATION FOR
PERT T TO
LOCATION
PERMIT GRANTED
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INSPECTO F BUILDINGS
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gPUM MIRE fNA04AD APPROVEO BY TW
MPZC=PIRM TO A PERMIT BMW GRRANTkD
CITY OF_SALEM
No. 967
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Permit to: BUILDING PERMIT APPLICATION POW
(Chb wham wr apply) Roof. Reroof, Im M Siding, Camstmxt Deck, Shed, Pool,
Rspair/Rspkm. Other. Sn -t
PLEASE PILL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCOMM
TO THE INSPECTOR OF BUILDINGS: '.
heroby applies for a permit to build amr&-q to the folk► ft
Owners Name
Address A Phom _0 L,► lCt- &i- ( 1
AmhkWs Name
Address d Pharm ( 1
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SIBItlD UNDER THE PENALTY'
OF PENURY
DESCRIPTION TO BE DONE
L ✓J iAbu) 5 g7d ( poar
MAIL PERMIT TO:
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
MIAC( F
DATA
CITV OR 3ALSM9 MASSACMUSICWS
PtIIUC PROt'1RW DCPARTMEMT
r ( 120 NWMINOTM SMIUM, US)/LOOK
IALaM,MA Of 070
TaL. (978)7//-f8N 9W. 340
Is /Ai (970 74&""
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I w chow SUMS ragwm(hat debris hom dw dm1oh
ua rmov ease rehab or other
altaadoa Ofbluldmg or*wan be d Voeed it a p gwly-Hceosed lob&waete disposal
hc&y m dedaad by MCL caL SISt& and the boil ftpamits or ka w m to
ia�as localise of the htality.
ueparrmenr of inausma neeraenrb
Office of laws4fidans
;f 600 Washington Shut
Boston,MA 02111
rvtvrrunrastgot✓tita
Workers'Compensation Insurance Affidavit: Bugders/Contractors/ElectrldamlPlumbers
ADDHcant Information Please Prid Legibly
Name r �
Address: lei '�(' a '�� -�
City/State:/Z.ip: fLj c Q21 Mc, n i ci 3 a Phone#:_ q7f3- 4,1 3 - g l a 3
Are you an empleyert Cheek the appropriate Iron: Type of project(required):1.❑ I am a employer with 4. ❑ I am a general contractor and J
_,dmployas(Sin and/or part-um).* have hired The sub-connack rs 6. ❑New construction
2.UA I am a sole proprietor or partner- hated on the attached sheet t 7. ❑ Remodeling
ship and have m employtxa These sub-contractors have S. ❑ Demolition
working for mein any capacity. workers'comp.insurnm 9 ❑ BuililinB addition
[No workers'eatmp.insurance 5• Cl We are a corporation slid its
required.] ofi9cers have exercised their 10.❑ Electrical repass or addition
3.❑ I am a homeowner doing all work right of eaemptim per MGL 11.[3 Plumbing repairs or addition
myself[No workers' comp. a 152,¢1(41 and we have no 11.0 Roofrepaus
insurance required')f employees. [No wodtaa' 13.0 Other
comp.hismanoe required.]
•Any eppliemt stet checks tape ei mot oho®!out flee action below aleowhg Oak wgatn'mnpardw yoliry,mfmmNos
t Homeowners who ahmt this sffdavit a icaiog dray ram doing an work and men him adoile aosetrnixan must sukout a new eff&vk ic&Ating suck
tCentrecton met check this box unlit attacked no dditionsl sheet.bowing me rage of do mbooenacYas ad their wodwe eon;.pal q ntro+metias
I am err employar that lr providbes workers'eompew edow btsurmeeejor my employees Below h floe poft end job sW
Info wNdea.
Insaance Company Now:
Policy#or Self-in.Lic.N Expiration Date:
Job Site Address: Cyh,/statvq*
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of ahnh l penalties of a
fine up to$1,500.00 and/or one year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Imestigatiens of the DIA for insurance coverage verifieWdon.
I��'�CUJ " °1Pe►Ja+r that the Lrformaafow prover!above 8,>.as ewe eonees
Sire: Date
Phonic q�B- 4� 3- c► a 3
e$oletel rase only. Do nor wrbe In tk/a arse,to be computed by c/y or ow o kfilt
City or Town: Ptrmitlueem 0
Issuing Authority(eireie one):
1.Board of Health 2.Building Department 3.Ckyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Otheer
Contact Person: Phone#:
- 1
r Mea
Massachuseus General Laws diaper 152 requires all eaQbyen 10 provide workers' n contracts of um
Pursuant to 0m statute, au eal*yer is defined as"...every person in the service of another under any
express or implied,oral or writxf."
o or nM
An uaPbYev is defined as"an individual,pamership,associatb4 corpondon or d legal of dean*employer,antw of the
of the foregoing mpgpd 1n!joint ,sod mcbdIDi t1w legal ' retrer dw
receiver or UMMIe of an tndWW'al,parmerS*association or other legal entity,awbymg ermloyees
owner of a dwelling house having oot mine than three and who resides therein,or the ooarpsM of the
lling bouse
dwellmg bouse of anther who employe persons to al maintenance, f n cji em l y matrep be �io be an�"
or on the grounds or building tberefo sbaIl not because of such empbymeat
MGL Chapter 15Z 125C(6)also Stara that"every state or local licensing agency caw withbold the lsmssm or
renewal of a license or pera to operate a btislaas or to construct buildings In the eottnmonwed*for my
Wocusit sub has not produced acceptable evidence of compliance i&the Insurance cc VU rM� shaIl
Additionally.MGM e�pser 152,1uf (7)Stan be 6awol tmtll h nor erne of w®pliaoee w subdivisions
y of its Political
enter m1D any contract�b �ncc�tod a the enuacanL aUftW
requirements of this chap
Apptleaw
Please fll out the workers'oomptssation affidavit comply,by checking the boxes that apply 0Year tMatiou and.if
necessary,supply mb contracoorte)trame(a),add<aa(a)and phone number(s)along wnh their catifieate(s)of
hauranot. Lmrited I;,b ft Compaoia(Lip or Limited Liabih'ty Paresershipa(LLP)with no employees other than the
members or partners, are not slaved ib cony workers'compensation msurmoe. If an LLC or LLP does bave
esoploytxa,s policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurancewverap Also be care to lip sad date the trffidavk. The affidavit abouid
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Shoff you have any Tmt m regarding die law or if you are required to obtain a workers'
wmpensatioapolicy.pled call the Department at the munber listed below. Self-maued compama dotild eater then
Self- cc& me number on dw thm
Chy or Town Officials
Please be we that the affidavit is complete and printed k&IY. The Department bas provided a space at the bottom
of the affidavit for you ib IM out in the event the Office of Iavatigations but to contact you regarding the applicant
Please be sort to fill in the peroMiccuse number which will be used as a reference number. In addition,an applicant
that mart submit multfpkpermit/license aPPticatiom in any given year,nod only submit one affidavit indicating truistic
policy information(if necessary)and under"Job Site Address"the applicant sbould write"all beattom m (city Or
town}"A copy of the affidavit that bas been offieWly stamped or marked by the city or town may be provided to the
applicant as proof Q a valid affidavit is on file for fliture permits or liceosa. A new affidavit must be f fied out each
year.Where a borne owner Or citisen is obtaining a license or permit not related to any business or commercial venture
Y(ice a dog license or permit in barn leaves ere.)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 quatiomh
please do not besitaw to give us a call.
The Dopartmenes addtas,telepbone and fir mrmber:
The Commonwea dt of Massachusetts
Deparimcnt of Industrial Accidents
office of Invetdig dew
600 Washington Streit
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mam.gov/&a