15 AURORA LN - BUILDING INSPECTION fLi"1AtI6i'eE fiL*&MiD APMOVED BY TW
IdSPP. =VlWR TDA.PABWT AEING GRANTED
CITY OF_SALEM
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BUILDING PERWT APPLICATION FOR:
Pw"to:
(Girds whiotwvw apply) Roof. Rwoof. IfWd Siding. Construct Dods. Shed, Pool,
Rap"PAPl000. Ottw ...
PLEASE FILL OUT LEGIBLY i COMPIMELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF WADING&
The wWwaipnsd fwraby apfiu for a permit to build according to the loWwktig
ONW& Nwne Tbo r
Address& Phorw `� /},�c-vra �►�u l -7 u 1 - y-71 y
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SWdituro of Applicant
SIGNED CINDER THE PENALTY
OF PERJURY
OESCAIPTION OF WORK TO BE DONE
MAIL F RMT TO•
Li CobU"
APPLICATION FOR
PER1tt TO
LOCATION
PERMIT GRANTED
APP ov�u
OR OF BUI NG8 _
CITY OR SALS149 MASSACMYlt;T S
nustrC PRO►:a►ty CKPAAT?49MT
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31KEM. MASSOAMS " ete70
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PAM 87e-74&64"
Delyele Dlsoesal Fern
Is accacdana with the psovlabns of MM c40 3 A a condidoo of your
8nildins Pisrmit Is that the debris d ftm this work shall be disposed
offs a propedy licensed solid wssteloprposal facility as defined by MUL.
Chapter IM 9150 A.
The debris will be disposed of he
�orc.e.s a-e�
(r-ocadon otPacilityl
3fgaamrs of Applfc=t
7 �3 —v!o
Date
< Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www massgovvdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiorganmtion/Individual):
Address: ?7 yC5- 0i 1REgm,"� ST
City/State/Zip: Lt )G2CEs i ETZ Phone #: 4 7&— 5iA—457G
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 1Q_ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-_. listed on the attached sheet. t 7• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. [1 We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant that checks box p1 must also fill out the section below showing their workers'compensation policy infommtion:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tCmtractoa that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: t/�Y
Policy#or Self-ins. Lia #: /a (O 17 CJ 4� Expiration Date: 07
Job Site Address: city/State/Zip:
Attach 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 criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
:)fup 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 verification.
f do hereby certify underr naliies ofperjury that the information provided above is true and correct
signature: Date:
?hone#: 9 -7S-- 5&9 T
[6. only. Do not write in this area,to be completed by city or town official.
Town: Permit/License#
ority(circle one):
3ealth 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
on• Phone#: