19 WOODSIDE ST - BUILDING INSPECTION NC16
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Permit to: OULUMifi PNNW APPLACA M PDlh
(Ck b whbtwwr apply) Roof. Rdmof, InIWI Sift COnotn of Do* Pool.
RIPRIWAP10ok. 011Nr: 2-�moLAEL rzv�-c-u
KUM PEL OUT LM LY a COMPLEMY TO MM 0lLAYO N PIIpCEiOOq
TO THE INOPKjWl OF 611I1OINOfi: '.
�undtxdiprnd NOW dpPlNd for • pw* to hulid 0000miftto do ImNowirq
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AmhbWs Norne
Address a Phorm I f
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DE>iCiOp�1ON OF WOIMI TO IN DOLE OP Pe1utm
MAIL PEFANTTiO;
ueparrmerrr q inaustnv Accraenra
O,Pe ajhnersr 4611s
9 600 WeAlnatoe ShM
Boston,AM 02111
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Workers'Compensation Insurance AM&vit: BnHderalContradors/Eledrtdam/Plnmbers
ADDNtant Information pl«m
Name (ZO%� L.ASnub
Address: 19 Woofl,�TOT Ej
City/State/Zip: SAcfL1' M A Olq� - Phone t �(7
Are you as mpiger!Cleek the approprlese born
1.❑ I am a employer with 4. ❑ I sto a geoasl wnaactor ad I TYPO atproien(rimed):
employees 0A alwar part dme}0 have hired the subcomrsam 6. ❑New coauaacti s
2.❑ I am a sole proprietor or partner- listed oa the attached sheet 1 7. ® Remwddmg
a*and have In employees 'these alb-oontrscoora have S. ❑ Demolition
washing im me is OW capacity. worker'comp.(ttsalsace. 9. (] > L addition[No wod;er comp,ioaurmoe 5. ❑ We are a corporadu and id
offioos have a mcited their IQQ EbeWW upaila or addition
3.0 I homeowner doing all wed[ right ofenaptioo per MGL 11.0 Phtmbisg repairs or additions
Myself(No workers' comp a 152,11(41 said we have no 12.Q Roofrepsh
manses te44�)f 13.E Other
regauettj
•Any SPpamttt arc cbmb box/1 umt dais®out on mchm bdow newly tlmir wmiea'omtpmmao�PAq mforM5dMI
t Honeow=n wbo mbmk AY idwh and croft dwy=dabs ra wok god Sm bus condo MuftcWn aims wbmk•tow @M&vit mdcnthu rnok
fQwtr w slot rbwk dda beat not trrbed o addMood ohms drw*for o®r afar mbcobbac$m and tbdr woea w omoP,Poft bdbrnwsjoa
t an an sstplsya rAat is PFOAMW rrvrAers'eosrpesssflwa braanrrrt jsv cry arrployess Bdow b dkeD 7 sat Jai star
b onsa*06
Insurance Company Name:
Policy 0 or Sel€ins.Lie.8: Expiration Date
Jab Site Addles CiwStateAzip:
Attach a copy of the workers'compensation polley dedwatbn page(showing the poBey camber sad aplradoa date).
Fa17n1e to sma coverage as ragwred undo Secdon 25A of MGL a 152 can had b the imposition oferimiasl penaitien of a fine up to S1,SOO.00 and/or one-yew mtprisonment,as well an tiv11 petwlties in me form eta STOP WORK ORDER and a t5ae
of up to 5230.00 a day against the violator. Be advised that a copy of this statemwt may be ferwuded 10 the Ofgcx of
Investigations of the MA Ex hmm oee coverage vaifi ados,
IAskd iryc ,bep"na dbra d/esjosyrryrlwa AslxfwueaionowadabowitOw atewrrea
O&Ad tstt osbt, Dr no wrdsr In A&Bros,to be eosrpfertai y cdd or Amu Orldd
My or Tows: PvmlNlleeme 0
Iuning Autkorlty(drde oath
I.Board of Health L Building Department 3.Clty/rown Clerk 4.Electrical Inspector s.plumping Isspe eW
6.Other
Coated Palm Phone 0:
Maasachusetti ter 152 requires all emPbYas to provide worlat' n as unu Z
Deueral I svn cbaP is the service of mother under soy contract of bk%
Pursuant to this stsolu, an sarpbyw is defined as ...every Person
cxvm or ivied,oral err wntos
aswGatiM corporation err other eased n I Y HMO 9 Hate
60
Act awpfOYw is dew"an vidnal.� a othe 1ept _a of a deceased e>nPI However 60
oYQ
of the forwiot in a joint eexmcsibentity,emPioYio�emPbYe�
vAn
receiver or vow of andjud ���duss duce�add a Uci1 Or 121 oaO a dwe» 6oitl0
owner of a dwdlist wbo crop"Pcnon b 8D mamtensnoe. ben doomed b be as ewptoYwr."
dwelling bouts of asotber thereto shaII because of strsh amploYmms
or oa the pounds or balding aPP°rtmaaa sYA��the��or
MGL chapter 132,425C(�goEVLe "N�'too or 10a1 tleaerl�apse!
far an
to qWw a bedsaa err t0 tatitt�baildla0 b the l0of��
reseed d a e lug or am �ed as rtel*"mom at C0°P0e with the teases eaerai rogelssd. shall
appMena mssib,idm cjWW.15%12SC(7)�"Nchbw the comsoonwalA "or seY of its
Poftal
ofpublic wtodt usttl W"Ptable evidence of cosgplisew wry the inttsras,os
ester into MY tpntract��sror to the waDtactieL totita�Y•"
wq�mmts of thin chap
AppUcONO the bo:a that apply to Yaw �'if
Plans a oat the wrorlceta'amP affidavit completely,by mumbedoci � Wa their catitfoate(a)of
s)wtc(s),addras(e)and phone�mba(s)abni
necesuy,nupPbCmPades or Liostted I.isbt'HtY PattoaahiPt(�wMh no euiPloYees other rhos the
insurance I ad raloired to 0° 0 if as LLC or 1 �� y
members Or Par uy� advised that thin affidavit may be submitted b the DMUoncot
employees, bus of immeoce ouvaagn Alas be rare to sign and date the aflldavk. Ibe atJfdavi<ahoDePWOMM oufld
bAccidents e Waned b the citY or sown that the apptiation ibr�permit or liot ate is berm equig e to d, 000b�as wodtas'
lndn4trid paidenq Should You base any goestion rc adwa 1bE Ltw or dyoa are n4
a policy,p�call the De OUNI t
At the enmber listed below. S&insured cowpswie OWN aster dMis
uif-intimma fiade mmba on ins
liter
Ci4 or Tows Olfielsla The Depatm�ent hat provided a�at This bottom
plase be came that the affidavit is 000•P1ea Printedlegibly-, bat b contact You TCPUIisi the nPP*A'M
of the affidavit far you to fill out m the west the Oflses of Imro astionn In n,an app�ffi
plane be sure a fID in the pa Micease number wbkh wM be used SOa reference . addition,
curren
that must submit noslWls PawiVhCC°tC WPlicatiom is mY given Yam+need°nlY submit one affidavit
policy Wor asson(if neeasary)and under Job Site Addree"the applicant should writs"aII locutionsbelis (rw a
that hat bees of&.b*stamped or wanted by the city or tows mar be provided b the
town)."A copy of the affidavit it a Me far ihtun pamio or license. A new affidavit must be fined out each
app a this a valid sflitiuvit a tfi=e or permit a business a 0d°°ICrS'venture
y Whoa aMWM owner W edam is obWaiai �related my
ya a b litxaro err P�b bras laves ere.)raid pawn it NOT nVJred to omm IM this of ldavih
(je
The Of6a of Imati�om would ltte a thanl you in advance for your wgaa*m sad abound you lave MY quadona,
please 8o notheWte to iiYe>b a Cell.
DePt apt,telepbtme and fens wtwbert
The Ca®monwealth of Massachusetts
Depa tnetn of laduslrial Accidents
Of11a of Invedipdons
600 WashiMgtoa StMd
BOSH MA 0211 It
Tel. #617-727-4900 eat 406 of 1-877-MASSAFE
Fax#617-727-7749
Raised 5-2" wwwmm.gov/dia
CITY OP SALSM, MASSACHUSETTS
PtJaue PROPstttrl►DCPAWM[NT
120 VAIM INaTON SMSI T. 340 FIAMOR
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Tal c0701749-11ee6 CRT. 340
PAR (07%740-08"
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11w&bow $MM raqum that dabria Am tit dtmobdM rmovadM rehab or other
altaaws otbmWinj or*act=be diVmW im a p mpttly bcaoatd solid-waw diapoaal
fAary at dc&W by hM ca SISo&and tbt building p Wtp or lieaoaoa are oa
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