009B FILLMORE RD - BPA-07-625l
CITY
PUBLIC PROPERTY
DEPARTMENT
FIMIFJI"ONSCOrl
Mwraa 120 W,WUtKi1S STRGGr•
TzLV&74S-959S 1:FAx:M7i0.9M6
APPLICATION FOR THE REPAIR.RENOVATION, CONSTRUCTION.
DEMOLITION.OR CHANGE OF USE OWOCCUPANCY, FOR:ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
LocatiooName: . Building:-- -_-..__ :.-._-_.
propeny VNO re
property ib kx:al in a: Consmation-Area Y/N - HisWfti DWMd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Ge® c W
Address:ore,
salmi
Telephone: q1 -f 51R
3.0 COMPLETE THIS SECTION FOR WORK-IN EXISTING BUILDINGS ONLY!
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building New
8def Description of Proposed Work-
Re"0q(>- ' 1 tCerco
U_es Aox 1 1 rnoe1 f;Q(E,, Pew dA(/nne_t,(
Mail Permit nS uc n a ^ 0
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnaat trav nttncoti
ata,roa
120 wAs*w4G art STaasr e SALEK 1 75E r'[S 01970
TEL 978.74S9S95 a Fix:97E740.984
Workers' Compensadon Insurance Affidavit; Builders/Contractorsmec&icians/pinmbersApplicantInformadon
Construction xatarsse Print Lt'Qibhr
Vtesi4aORa6'a
Name(Busiseworganiadowbught)Rrsv C4
Aug: Stoneham, MA.- 02180
City/stateaip:
Areou an emplayer?Check the appropriate boa:
1. I am a employer with Q_ 4. 1 am a general ccnftctar and
IF7.
required):
emPloyees(Bill and/or past time).' have hired the sub contractaa truction
2. I am a sole proprietor or partner. listed on the attached sheet t ig
ship and have no employees These have
nwontingformeinanycapacity. works='comp,ioamma&(
No workers'comp.insurance 5. We are a corporation and its addition
inquired.) officers have exercised their 10.0 Electrical repairs or additions3. 1 am a homeowner doing all work right of exemption per MGL 11.Q Phunbing repairs at additionmyself.(No workers'comp. c. 152,§1(41 and we have no 12.Q Rooerepairsrequired]t employees(No workers'
13.[ VnCamp.insurance requiro&l
ARY WHOM tW dwhs boa#I mast van an as tbo atadw blow shmio=thdr stothmaHampwm
t
ohs athmb
box now so
tMy ua&ft as aaak imd tt+•h6a atadda o w submit tmaatIIdadttCosaaemssthischockthbtwomintaasehadmadditlaovabutshowiastherumsofdwsob.ramtapma sad thh sahssa•osmp PAW inIamanemployerthatVprovidingworkers'rompensodow h+sttrancejor my earployeet Below ter dueInformation Pogc!andjob slM
Insurance Company Name:
Policy#or self hoer eio #_ W Do S/ ('6 6 F, 0 Expiration Date:C7
Job site Address:_ 9 j F/(LL li l D k L—' U ei /s
Attach a ropy a[tIw workers'con aaatbn
ry tuuZrp.
tic policy declaration page(showing the POIk7 number sad expired@&deft),Failure to secure coverage as required under section 25A of MGL c. 152 can lead to thefineuptof1,500.00 and/or one-year imprisonment,as well as civil penalties in the form oftenSTOP WO RDER and a
ion Of criminal panel tin of
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OtDE a
Investigations of the DIA for insurance coverage verification
Ida hereby cerdA under the pains and nalder o!f —cry tkat due Injormadow provided ebo Is Arne and tarred
Phone
oQlelal tue onl t Do not wrkg Gs thir area,to be completed by cry or town ojj&laL
City or Town:
PermitAucense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector6.Other
Contact Person:
Phone#-
Information and Instructions
Laws chapter 152 requires all employers to provide workers'compensation for their emploYea.Massacbuseas Gened
yee defaced as"...every person in the service of another under any contract of hire.
Pursuant to rhis sumac.an
express or implied.oral or written."
a an two or moms
association,corperaton at°f legal a
sled
y
An pfeywrs is defined as"an individual.partnership.
g the l"Al repirsmunves of a deceased employer.
v
the
of the foregoing engaged in a joist enterprises
assmatm or orher e> the occupant wehe
the
receiver a trustee of m individual.partnerahuP. who residesof the
owner of a dwelling bouse having not MAX°than three'Partments andction or reWir wodc an sorb dwelling hww
dwelling boom of another who employs P OOi a do mainc nauoecee.
employment deemed to be an employer
or on the pounds or building appurtenant therec sht
1--ate ' . ia5b'.9akP .txy
r_< slj-witbbold the issuance or
MGL chapter 152.42SC(6)tilt°states that"avert state or local tlew,
V)IN t eommoswes"for an!
beildis,0,..to opera,a bud,o.`ia'rbi coverage requhvd.
ap
renewal et a uaase or permit acceptable evtdeaa of eomptlaace wkbthe iasannce
appgeant who has net produced states"1Veuher the commonwealth nor any of its political subdivisions
Additions MGL chapter 152.$25CCn
p work until acceptable evidence of compliance with due insurance
enter into any contract for the perlbrunaoce to the contracting authorityrequirementsofdtischapterhavebeespresented
Applicants she boles that apply°your situation and.if
Please fill out the wodere' compensation affidavit completely,by checlana of
necessatY,supply stb4onnx s)name(s),addreat(a)and phone numbers)along with
other then the
insurance. Limited Liability Companies(I.I.C)or Limited Liability Partnerships(I
f
P)
are oat required to carry workers'c°ta°insurance' If an LLC or LLIof Iadust<'
members of req red Be advised that this affidavit may be submitted o the Departmentemployees'
re insurance coverage. Abe be sore,alg•and der,the afisdavlR The affidavit should
Accidents for confirmation the application for the permit or license is being requested,not the Department of
be returned to Sh
town dWouldyouhave any quat a regarding do law or if you are required o obtain a workersInduarialcompensationpolicy.plan call the DapasomM111 at the number listed below. Self-loaned compames should enter their
self ioaaence license member on the
City or Town Officials
at
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space
of the affidavit for you to
the bottm
fill out in the event the Office of investigations has to contact you regarding the applieant.Please be sate o fill in the perrojoicense number which will be used as a reference number. In addition,an applicantlicatiorsinanygivenyear,need only submit one affidavit indicating current
that must submit multiple permidlicensa app
applicant should write"all locations in_____(city or
policy iafamation(if necessary)and under"Job Site Addreu"the app ' city a own may be provided o the
of the affidavit that has been officially stamped or marked by tY
own).-A copy firm permits or licenses. A new af"-&vu must be filled out each
applicant as proof that a valid affidavit u on file for not related to any business or comrnereisl venture
year.Where a home owner a citizen is obtaining a lima
is NOT t
a permit not
re to complete this affidavit
i.e. a dog license a permit to burn leaves eo.)said person
The office of Investigations would like to thank you in advance for your cooperation and should you have any question4
please do not hesitate to give us a call.
The Department's address.telephone a
wedth of Mg1Wgehtuett3
Depalhaent of kALS tial Accidents
09ke of InvesdgWons
600 washM91M street
Boston,MA 02111
Tel. #617-727-4900 text 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26.05 WWw.ID mpV/dig
Crnt OF SALEm
PUBLIC PROPEWN
i
DEPAX MENT
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What iathe current use of the Building?
Material of Building?
O If dwelling.how many units?
p
Will theBuilding Conform totaw? Y 5 Asbestos?
Architect's Name:
Address and Phone
Mechanic's Name' i
Address and Phone
Construction Supervisors Ucense# HIC Registration#
Estimated Cost of Project$= Permit Fee Catcul illm
Permit Fee S Estimated Cost X S7/51000 Residential
EstlmatettEostXSfq . -
An Additional $8.00 is added as an
Administrative,charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above,stated ii
specifications: Signed under penalty of perjury
Date
N
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