17 BUFFUM ST - BUILDING INSPECTION 0
-PLiWS11AIf1 T*Ef NG APMOVED BY THE
.W WX=W PWR TD A.PEAIf T AEING GRANTED
CITY OF_SALEM
No. Data
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""mock Dm1W Yai No_ 1101 ins
Is Ptopady Lonlad In
ma Caranation Ana? Yam No_
PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) „Roof, eroof, Install Siding, Construct Deck, Shed, Pool,
dReplace, Other:
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCESSL40
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name Mitc. 14r ,iPL,A
Address & Phone v r, . C - (7 M 3,SZ,51 6S 6 7
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone C�
What Is aw putpoa of W Wkp? \\ c
Mamttai of hfidkq? OAJ(1'n r( a a dwaWtq,for taw many famWaa? T
Will WkbW confam to law? Aabwtos? �3 0 2 /�
010 Cqy Llow"M N ' slam ucwue 0 J/ v
>�. Iapso�nt X��
- .
1pnature of Applicant
SKiNED UNDER THE PENALTY
OF PERJURY
]]ON OF WORK TO BE DONE P r�
M«
MAIL PERMIT TO: 1�& (J
No. _LZLLS�S�
APPLICATION FOR
PERMIT TO
LOCATION
7
PERMIT GRANTED
/l/3h 2.e
AP o PD -
INSPECTOR F BUILDINGS
' f d
The Commonwealth of Massachusetts
Department of Indus&W Accidents
offlee of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dta
acorsElee t gi Workers' Compensation Insurance Affidavit: Builders/Cont pse PLebl
Aniplicant Information
Name (B pt :atiou/lodlvtduaq.
Address:34 -
City/state/Zip: M' .. 1 \p�h �� �I9tfgP'hone#: 9�r�}
date box:
T
ypeproj
ect
Are you u employer?Cheek the approp 4. I am a general contractor and I
1. I am a employs with employees(full and/or part"time)•• have hired the sub eontrdctorslisted on this at ached sheett2.❑ I am a sole proprietor or Partner- Tbese sub-contractors have ship and have no emPloYeea workers' comp. insurance
working for me in any capacity.
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.C] Electrical repairs or additions
required.] officers have exercised then repairs or additions
3. I am a homeowner doing all work
right of exemption per MGL 11.� Plumbing ep
myself. [No workers' comp. c 152,§1(4),and we have no 12.❑ Roof repave
t employees. [No workers' 13.[(]
insurance required] comp.insurance required.].
*Any applicant that cbmb box 81 inset also fill out the section below ebowine their workers'compenntion Policy infOim°ti0D'
they ere doing sn untie and then hire outside contraclora must suh nit.&new affidavit rodiceting such
f Homeownm who submit this affidavit indicalatg % the name of the anbcon clors and their wwkm'comp Pola.Y information.
tContracWts that ch«k this box moat attached an edditioaal sheet showing
I am an employer that Lb providing workers'compensation Insurance jor my employee& Below i r the policy and Job sale
Injo►matlon �/^�
Insurance Company Name: k (u V U G,6 a cA rtA H c Q r+t Or
M Expiration Date: / 0 6
Policy#or Self-ins.Lric.#: IBC
i
Job Site Address: 1. L u'�tU City/Stateizip: &,P M
Attach a copy of the worker' 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
fire 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 fins
of 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 ce under the pains pe ofperju►y that the information provided above h true and correct
Date:
S'
CM — 9
odkial era a* Do nor write in this area,to be completed by cUy or town qP'Jeld
City or Town: Permit/lAcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cky/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
11aAVl 111 is a.l Vli Kllu lx&o%,& %arw%,1%r&xo
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thek employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under my contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or.irstee of an individual,parnersbip,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing ageacy shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152,025C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fin out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. 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 affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lint
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has.prvided a space at the bou m
of the affidavit for you to 1111 out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permitJlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitticense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all I uatioma in ' (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(it a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26 OS www.mass.gov/dia
' o
CITY OF SALEM, MASSACHUSETTS
{ PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a!properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in: Yc�
T
1c)V� !i,e e- (Location of Faci ' y) 6 l%o
ignature o li
Date
ll � � �GJ� P�,���✓d1
Board orBaBdt%Regulations and Standards
ROME IMPROVEMENT CONTRACTOR
� Rapbbstlo� .,�08767
7}ipftartwt
_. MUSTO DEVELO�RMEA�'R_IN`.�O¢BOSTON
Gbvanrd MUsto
8 Maplewood Road`z .�•�;,�,-# .,i
Middleton,MA 01948 ` AdadnWntor
�� .;"�, °JiFe �oor�rorsanq�etilub o�./1'r!adda�udsl�d.
BOARD OF BUILDING REGULATIONS,
License; CONSTRUCTION SUPERVISOR.
Numi" . 023109 T
it fifiat /1962
Tr.no: 1650.0'
GIO`!ANNI MU
8 MAPLEWOOD Rpm
MIDDLETON. MA Oi Commissioner
1