17 BELLEVIEW AVE - BUILDING INSPECTION (2) __ t fN�Ei�I1D AfPROVEO t3Y TW
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JMSPF.0=PRIOR W A PEAWt RFINQ GRANTED
CITY OF_SALEM
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WAXING PEI WT APPLICATION FOR:
Pemlit ux
(Ckde W*hft r apply) Roof Remalined SWkXp Co *VM Dock. Shed, Pool,
Other;
PLEASE RLl OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF SUILDING&
The w dwaiprwd hereby apple for a permit to build according to the folbwing
OmW&Name P f W on
Address& Phone �—( ,'. )����_v yew AV. f 4-7�)
Amhkods Nano
Address A Phorw I 1
MWw 9w Name
Address i Phorw 3LI�
WIW Is w pirpooa d hWdlrp4_ ��S�dam..A�-,c 1 '
MAN"d twldrg4 \ I a e imq,for horn wny mm!"? �
vm kmov pm 'm r i w9 9
gowum am CIV L w'm r N A am,U",a
sine ia�ewmrwt
lse. I �a a X of Applicant
l d SIGNED UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DONE OR PERJURY
MAIL PERMIT TO:
tj
N0 y
APPLICATION FOR
PER1f<f TO
LOCATION
\-7 e v ,
PERMIT GRANTED
INSPECTOR BUILDINGS
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i
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual):: 1 7
Address:_ sz/S-
City/State/Zip: (4?OjW 95—Lep, Phone#: 4 7&- S&d-57 G
Are you an employer?Check the appropriate box: Type of project(required):
1.9 I am a employer with 1Q— 4. ❑ I am a general contractor and I 6. EINew 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
workingfor me in an aci workers' comp. insurance.
Y capacity. 9. ❑ Building addition
[No worker;' comp. insurance 5. ❑ We are a corporation and its -
required.] officers have exercised their I0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.E] Roofrepaus
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation poli
t cy information
♦,H� omeowners who submit this affidavit indicating they are doing all work and then hire outside contractor;must submit a new affidavit indicating such
iCOntracmrs 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 thepoUg and jab site .
information. / n
Insurance Company Name: /N/T7 l A5,J LD
Policy#or Self-ins. Lic.#: /o t 0 D Cf 4 Expiration Date: ?j /— O 7
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
)f up 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.
I do hereby cerdA under A ains aandpenalties of perjury that the information provided above is true and correct
signature: 77t//� Date
?hone#: 9 78- 5&4; 7
O
fficialonly. Do not write in this area,to be completed by city or town offxhd
Town: Permit/Llcense#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on. Phone#:
GtTY OR SALK149 MASSACMNSt;TTS
nustre PROPUR" OarARTiMstr
�20 wiuHommy onsa7. Sao RMO
9"80, MA..OMOUSS s at9"
TnssMoNa 970•749-NU 8XV. aq
De6ela Dlsoeaai Yale
Is mcmdaace with the p mvWm of MM co S.% s ooadW=of
Hsildln j Ptrmit our
is that the debda Y
, , i ftm thin warts shall be disposed
Otis a peopedy Hemmed solid wasoe
Chapter UL S 1J0 A.
0�tsd>;ry as dented by MC3L
IU debris will be disposed of in.
�JUS �' e e Gov `5+, c kDorck,6 I-c- i—
( Acatlm of Facilisyl
Sigaatare of Appiicast
Date