1 RIVERBANK RD - BUILDING INSPECTION What is"Currare use a dw OWk*97
mats"d eu�7dk+fi7 0,�, K dw+MrrO•now nary urtils9
Will to DA&V Cordons Laalr ® � Aabastoa9
Ard wft Nano ( 1 -
Addrrn ane Phan*
M@dta des NarrM
Addtaaa ane Phoma /�r i �%3 oo-3 X02
cman+edon SUPwI liar+.. HIC Rapiata6on
EsK. - i Coat a P"Od otJ Parrrrr Faa C
PsrmR Fee i Edknsled Cant X$71$1000 Raaldarvild
Edknatad Coat X fh i1$106G s.ae. :a ---- -
-- An A ddi6ond$6.00 Is added as an
Admkooradm cttarn-
Maks aura that am ftws an propwV and w9bN witten to avoid delays in prooassin0.
Ttra u 4WOWWd dam Eby appy for a SumdU6 Permit to bulid to the above stated
apad0oatbra• Sipnad under WMW Of°whir X
n
s �
3
17 $
EI'I'Y OF
PUBLIC PROPERTY
DEPARTMF.►�IT
11L.M7464M 0 PAZ M7464"
A1tPI.ICATION FORTH! MAJIL BENOVA'TItDN CONS�rQrrr-rrnnr
DIM01 TIODL OR CHANGE OF USZ OB 0901 nlrv_ FOR .,w ZXLnr> G
�UCTL�t 04 9�m�>►>�
.0 an INFORMATION
Loeadw NORM
irr�r `Jd-�
Properly Is loealed k a:Cawr Poll Ana YM HWAft DWW YM Vl
2.0 OWNERSHIP INFORMATION
11 Oweer of Land _
Nor+ 777er-r durravc
Address:
Tole~.. p
SACOMPLETE THIS SECTION FOR WORK IN EYISIWp J UILOINGS ONLY
Addition Exis"
Reravadw Number of Storks Ranovatad
Change in Use Pleur
Oemoudon
Approximate year of Area per Hoar(s� Renovated
construction or renovation
of existing building New
add Oescdptlon of Proposed Work:
_ ._
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
mmu ltl.Fy natio)LL
M vvaa 12C grastawrav S raa rr•SA1tat,htassAcl a. 1 rs olign
Thi.:97&745-+5% •F.sx:979-74G9a4@
Workers' Compensation insurance Aflldsvite Builders/Contractors/Electricians/Plumbers
Applicant Information '^J—`y / _ yp Please Print Legibly
Name tkluainvsstOrganiraritWltWtvtdtwq: Ir'Y// 7°Y /"/I C/✓Ii�LC� 0/ S� -�i'r� 7'' 5,yt
Address: J r2 I`J Y / doiP Sb-
City/st3mizip: Sa4t/ -, —
Are yon as erpkyor'Check The appropriate bon
IF
t(regdred):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1struction
employees(full a ullor part-tine).• have hired the sub-contractors
t am a sok proprietor or gannet- listed on the attached shed t iasship and have no amployueo Ther sutKontraemrs have onwanting for me in any capacity. workers'comp,insurance. addition
,NO workem•comp. insurance S. ❑ We aro a corporation and its !0. Electrical
requircti) officers have exercised their ❑ repairs or amirions
3.❑ 1 at a htsmeowncr doing all wont right of wremption per MCL 11.E3Plumbing repairs or w ticmmw
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.j t cmployccm(No workers' 13.❑Other
comp. imsurance mquued.J
nay applicam the dvxm hex al map 460 rill uta the action lxlow rhoaria/their avakms'ewttpsesathat pulley ittfmatatioq
Ilutnwtwrtaa who tubaW lair amclovii indicating Wry ma 4*g nd wwk and Wes him ou"We eomracem am"vtbn6 a aaw affidavit indimaing aa.h.
�C.,ntravvtas thn come oris hon nags aluehsd un additiwrl dtcn drawing Wa nam of Wr subcontractm age their wurimr'map.poltry mi llsmtsom
I um up employer that is providing workers'compensadon Guurance for my emp/oyder Below is the polity and fob We
iraforaution,
Im.urance Company Name: __ _
Policy g or Sclr--ins. Lie.p: Expiration Date:
Job Site Address: City/stataZip:
Attack is copy of the workers'compensation policy doclaratloa pall@(showing the policy number and esplratloa date).
Failure to secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
ri ne up w Sl•5410.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Cme
of up to 5250.00 a Jay against the violator. Ile advised that a copy urthis statement may be 1'urwarded to the Office of
Im'.•sngaumts ur the DIA for in:urarce covcrao varirrcatiun.
/do hereby certify under pa s and Oak' s of pert than the h oramAtur provided above is true and correct
unto Ax
/(�9
O/J7rialase onlp. As not write is this Oreo,m 6c rawpletad by city or/own o/fir imi
City or Town: Permit/License 0
Issuing Authority(circle one): _
1. Board of Ileaith 2. Building Department J.awrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone p•
Information and Instructions
their emPlOyceL
pursuant
s ant to this
General Laws chapter is deter atres''.eve y person in the service u another under anyl employers to provide workers' compensation «controa of hiiM
I'ursttant to this acuate,an ewPloyte
eapress or impl4A oral or written"
Ann erwpreyr is donned d"an indivithul.parmmt6tp.
associauos.corporation at other legal rarity.or any two a mac
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deeersed employer.or the
�ssoeiatoon of other legal catity.employing employees' However the
owns O a«utw of as se having
of more
sht e � and who resides therein.a the occupant of the
owner of a dwelling haute hho eg not mote than three main rain or re work on such dwelling house
dwelling house of another who employs Persons m do maintenance.construction Pair
or on the grounds or building apputrensm
thereto and net because of such employment be deaned to be an employer."
MGL chapter 132.423C(6)also states that"every state or Total licensing agency dhaa withhold the issuance or
rote a basisets or b tossbrud btdldlsge In tht commeswealth for stay
renews!of•!cease or perm![ to ops atilt��•of mwpUssce with-the insurance coverage requirW
appliessi who has net prodeced accept either the commonwealth not any of its political subdivisions shell
Add kwolly.MGL chapter 152,$23CC((7))states public rk until acceptable el vidence ofcompliaace with the insurance
enter into any contract for the pert authority-*of this chapter have hien presented to the contracting
Applkante
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and.if
necessary,supply subeostrecear(s)name(s).addreas(es)and phone number(s)along with their certifica t) than
insutynce. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employ
00 Other the
members or partners,are nes required to carry workers'compensation ins= A- 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 sign and date the affidavit.
The atpartmt should
en
be returned to the city or town that the application for the permittr low or e is if out are required not to obtain we t of
ca lwurial tion pe cy,Should you have any menquestionsshe regarding�listed below. Sclf-insured companies should enter their
canpensuioa polity.Phase call the Department
at self-insurance license number on the line.
City or Town O@elsb
pleavc be sure that the affidavit is complete and printed legibly. The Depatanent 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 till in the permittlicettse number which will be used as a reference number. In addition,an applicant
rmitilicense applications that must submit multiple Pc
ions in any given year,need only submit one affidavit indicating current
Site Address"the applicant should write"all locations in (city or
policy information lit necessary)and under"Job
cnailY stamped or narked by the city a may ay be provided to the
town),"A copy of the affidavit tbat has been off
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
hamyear. Where a haowner or citizen is obtaining&license or permit not related to any business or commercial venture
t i.e.a dog license nr Permit to burn leaves etc.)said person is NOT required to complete this affidavit
Che Ot rix of Investiga[ions would lie to thank you in advance for your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The Department's addrem telephone and fax number.
The Commonwealth of Massachusetts
Department of industrial Accidents
0 of lavestlpde"
600 wasltingtm Strad
Boston, MA 02111
Tel. #617-7274900 ext 406 of 1-977-MASSAFE
Fax N 617-727-7749
2cvised i-2G-US www.num.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
al�us liev.%Ac%7.Q.SUv iu:�r.lLwcu u.L�1r.:9
Ta.Ww4p) 1•F.�9JraJaO+MN
Construction--Debris Dist Affidavit
(required for an janalitios and anovatiaa work)
In xcordanee with the sixth aditiea of the Stats Building Coder 790 CMA section i l 1.S
Dcbri%and the provisions of MGL c 44 S SII
9uilditA FWmk*._ _ _ is h med with the condtdoo dent the debris rcwidns Boos
this wort shell be disposed of in s ptuparly licensed waste disposal facility as defined by%tGL e
111.915"
The debris will be wmsported bY:
_. lmmr,u'Aoald)
rho ckbdswill be disposed oof in :
/�
n,.mr�rrx�t�ty)
3 ri
Aid -