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120 BROADWAY - BUILDING JACKET r � Certificate No: 288-13 Building Permit No.: 288-13 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical permits This is to Certify that theMulti-family located at .... . -- -- -- Dwelling Type 120 BROADWAY#2 in the CITY OF SALEM -- - - - - - - --- - - -- Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY 120 BROADWAY UNIT 2 This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires __ ___ unless sooner suspended or revoked. Expiration Date Issued On: Wed Dec 19, 2012 GeoTMS®2012 Des Lauders Municipal Solutions,Inc. --------- ----- -----"-----------------..---_ y Vii- • x� 120 Broadway 288-13 , GIS#: K 11065 � I � COMMONWEALTH Ol+'N1=ASSACHUSETTS Map:, Block ' . ''g .•i« ' ;== CITY OF SALEM Lor 0o�0 u4 � Cate,,oly. :. �r; REPAWREPLACiT, fPermit tar rsz1 3'-,o 19 '5 BUILDING PERMIT ESC Cost iii $ 9,000.00 &01. -., Fc� e Charged:' p $324.00 balance Due:fl' $oo �'�� -:W PERMISSION IS HEREBY GRANTED TO: CConst Class :w= ��-- %_ "'F' Contractor: License: Expires: P�' 'john Panitnpas General Contractor-87003 IL6T Jve 8.) 6800 1516 ' R2 p Owner: Acacto Pinto Applicant: John Panitapas Wits Lost. '` , w `AT: 120 Broadway#2 ISSUED ON. 01-Oct-2012 AMENDED ON: EXPIRES ON: 01-Mar-2013 TO PERFORM THE FOLLOWING WORK. GUT EXISTING APARTMENT UNIT#2 SECOND FLOOR NO STRUCTURAL CHANGE MODERNIZE ELECTRICAL, PLUMBING, INSULATION AND INTERIOR FINISH jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: . . . Underground: Underground: Excavation: Service Met Footings:- i (t` t p) !z Rough .-�� ��. Rough: . `�.+A ) / Roug1o1.� (/ r�~ �t Foundation: Final: Final r v Final: ` Rough Frame` w ` Fireplace/Chimney: D.P.W. Fire Health Meter: Oil: ^y " 1��- Insulation: Cl qq Final: ,w jay .Dno.c_� Smoke: L� C��l Treasury: \Vater: Alarm: Lia,,--SS0r Sesser: Sprinklers: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee RTANT_OWNER OR CO Date Paid: Check Nu: Amount: ' A4 AnN6 TOE N)*AjBiA14.at:ST BUILDdS'lq?7 C INS �G 01-0ct-12 cash $324.00 STRUCTION.SEE CURRENT"BUILDING CODE CHAPTER 1 FOR LIST OF REQUIRED INSPECTIONS. CALL 978-619-5647 TO SCHEDULE AN INSPECTION GeoTMS a 2012 Des Lauriers Municipal Solutions,Inc. t� . i h , . i .COND[T,�� %1 • W N • - A_ VSgVE AD CITY OF SALEM J4-oG�o The Commonwealth of Massachusetts UlfDepartment of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 126 ?0 QU4Y SflLErn ✓17 A 297G No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2 PROPOSED WORK Edition of MA State Code used if New Construction check here❑or check all that apply in the two rows below Existing Building Repair Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No A Is an Independent Structural Engineering Peer Review required? ,/� mnLp C/D p� Yes ❑ No A Brief Descri lion of Proposed Work: .S �` `` G r F t (VCR UC yr 6W SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA - . Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft)and Total Height(ft) SECTIONS:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ I H. High Hazard H-1 7 H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ & Residential R-1IX R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal• Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ permit is enccll or indentify Zone: or on site system❑ required❑ trench or specify: osed❑ Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: /Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNEIj ORIZATION Name and Address of Property Owner Name(Print) Nb.and Street City/Town Zip Property Owner Contact Information: ��( p 2 g /�� Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes 7\tZh!N QaNn T QC . R-0�, y0(aS rnA C19! I Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized b this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control a (I;egistrant)_ Telephone No. e-mail address Registration Number 1-OtvE(L S)` Prfi�c(1 AOL& Q96C ( �C- /C3I/��i? Street Address City/Town State Zip Discipline Expiration Date 101 General Contractor m ej)A-F6e8,S' Company Name H n l�r CS g7oa 3 is -AG -/3 Name of Person Responsible for Construction License No. and Type if Applicable `�RW HO m 01 9 66 Street Address City/Town State Zip 7gor 0hNPAPOA08f E H ra;I,C-" , Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit Is a signed Affidavit submitted with this application? Yes)K No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ O 4' Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ p t0 120 4.Mechanical (RVAC) $ Note:Minimum fee=$ (con t,J/ cipaB ) 5.Mechanical Other $ o00 � 1y Enclose check payable to 6.Total Cost $ °= (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the Nstfiy mowledge and understanding. :C(A�N Ivyw s !Cn7rAc[ 9-N-`col2 Please print and sign name Title TelepVo. Date y�So 1.i,w�LL !\ F A A Street Address City/Town State Municipal Inspector to fill out this section upon application approval: ` - Name Date V � The Commonwealth of Massachusetts a �. Department of Public Safety 1/ �� '' blussaehusctls State Building Code(7811 CM1IR) f °"c3 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) U Building Permit Number: Dale Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Q6t'ofg/�wt4y S,1 Fwt M 1! o/9-2a No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Qj Edition of MA Stale Cudc used If New Construction check here O or check all that apply in the two rows below (� \ Existing Building❑ Repairik I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Via. Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: l�jZj Are buildingplans and/or construction documents being su lied as part of this remit a lication? Yes .R V / g VV a F 1 VV No ❑ v Is an Independent Structural Engineering Peer Review required? _ Yes ❑ No Brief DCS,TI tion of Proposed Work: 2� IV C.— llec C-- 2 117� T ev-\o e r,t _ w SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 /0qo ( o y a Total Area(sq. ft.)and Total Height(ft.) 11,01YO 1 12 sArtl� SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazud H-1 ❑ H-2❑ H-3 ❑ H-4❑ 11-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ Id❑ M: Mercentilc❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage Sl )$. S2❑ U: Utility❑ Special Use❑and please describe below: Special Use ' SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IL\ ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VBV SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) _ Water Supply: Flood Zone Information: Sewage Disposal: 'trench Permit. Debris Removal: Public ublic❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will nut be Licensed Disposal Site❑ required ❑or trench or specify:_ _ Private❑ or indentify Zonc or oil site system ❑ permit is enclosed Railroad right-of-way: hazards to Air Navigation: )L�I,i l<�.,�rir t.i mum.stii.ni 1=,}-i!:!r I'i y1r,� Not Applicable❑ Is Structure wilhin airport approdch area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:._ Use Group(s): 1)'pe of Consl runt ion: Occupant Load per Rnnr:__ Dues the building conlain an Sprinkler System?: __Special Stipulations: SECTION 9: PROPERTY OWNER AU'TFIORIZATION Name and Address of Property Owner A—,AC--4-'0 �O l�Li 6d1<i�ocv y_ S��e wL ©/970 atN ne(Print) No.and Street - City/Town Zip Proper weer C m tU t orma nl: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes YCBU R&Y-MeAy ra. goy, Loos— Name Street Address City/Tow n� State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Constmction Control then check here O and skip Section 10:1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor In H fV InBi`Iwpo f Company Name Name of Person Responsible for Construction License No. and Type if A4plickle (?.0 - (Joy- &/06$7- ✓tv r) Gl9G/ Street Address City/Town State Zip 72 Loi as Twa mayy-meal' Telephone No. business Telephone No. cell e-mail address SECTION 11:lti'l Ci WN NSA HON W:=uR,NNCG X 1-11 AVI I M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of a issuance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here ?. Electrical $ appropriate mum ipal factor)_$ 3. Plumbing 4. kledwnical (HVAC) $ Note: Nlinimum fee=/$�(contact municipality) 5. Mechanical Other $ Enclose check payable to .. G.Total Cost $ (contact municipality),md write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best if my wl rlge and understanding. T42' p' Please print and sign name Title Telephone No. Date �iEA(3arJt/ w7la p/9Ge Street Address City/rown S Zip Municipal Inspector to fill out this section upon application approval: ; ` rI anre Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CNIR) Building Permit Application for any Building other than a One-or Two-Family D Aellng (This Section For.Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not av ' a I /Ro G/ ol?,owny 5'1z'cr✓1 Me 0/9?o No.and Street City /Town Zip Code Name of Building(if applica V SECTION 2:PROPOSED WORK Edition of NIA Suite Code used If Now Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition J7 (Please fill Out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:DeM01is1-/ -/z dF EXISTin q Gf12A Are building plans and/orconstruction documents being supplied as part of this permit application? Yes ❑ No x — Is an Independent Structural Engineering Peer Review required? Yes ❑ No X, Brief Description of Proposed Work: k s 1 r( " x�5 rr�- r �.v 1 e- cn e e �r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CNIR 34) O Existing Use Group(s): _ Proposed Use Grou p(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) / L106 — Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ 1-1-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ 11B ❑ ILIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Rern vai: public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ required ❑or trench or specify: Private❑ or indentify Znnc. or on site system ❑ permit is enclosed❑ Railroad right-of-way: hazards to Air Navigation: \I.A,I_IiHnr Not Applicable❑ Is Structure within airport approach area? Is their review completed? Or Consent to Build enclosed❑ Yes❑ or:NO❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition Of Code: ____Use Group(s): "Ivpe of Construction:__ OccuPattt Load per Floor Does the building contain an Sprinkler System?:_ _Special Stipulations: A r SECTION 9: PROPER'TY OWNER AUTHORIZATION Name and Address of Property Owner ,cAGzG px1.To 6, OErv-PS Sy PFRlsofl y MA 101?4 sr Name(Print) No.and Street City/Town Zip Property Owner Contact Information: `Title Telephone No. (business) Telephone No. (cell) a-mail address If applicable, the property owner hereby authorizes ZahN PAr�TAPAIJ ej,. aox Ho6s— P�saaoy m o1g�r Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative hp work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,OW cu.ft.of enclosed space and/or not under Constmction Control that check here and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 7aHN 91ArrrAw�s Company Name 7VjNN PAN-m9R1 M f1 CS g-2003 /e/IG // Name of Person Responsible for Construction License No. and Type if Applicable P-a- Gd-- t-OCgE PeFARg0\-/ w A c0,6 Street Address City/Town State Zip 78"-W- 7dOS-- 0NnPONTOPAr l-A,7vt,re-+ c_ Telephone No. business Telephone No. cell e-mail address SECTION 11: 1111 NLSA I'li N m 1-114\Vl I M.G.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? YesjY, No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=S 3. Plumbing $ 1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact nut nic ipality) 5. Mechanical Other $ r� O Enclose duck payable to J 6.Total Cost 22 $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest n IZerlpains and penalties of perjury that all of the information contained in this application is true and accurate to th est mvl� ge and understanding. �t� ers 9�Fs_ i Sao rs/2y <i Please print and sign name� �p o � t .t,t t c "Title �Tcic h nc N p Late 0116 ( F U t Street Address Cityity/Totvt�T S- e Zip Municipal Inspector to fill out this section upon application approval: Name �`�A ` ;L.�Mm P CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT nm:s:r r,istutn t N t n tl( 12C WAHa.\G It^SIX EI:)• s $u F.M.M.vac.w.w a i rs;rl97: I'ra.:'I7})ti'/i'l3 o hors Wx•71C•'+846 . Workers' Cumpensatlon Insurunce :%M(favit: Builders/Contractors/Electricians/Plumbers itoollcant Information Plc to Print Leethly C ;i9(y T� V' /V JCJ/� V8n7C IllueiteviQraanvmiorvinJiv�duull: . ^19 Address: 00 , I30,K Nle)6 �__ Cily,Statc.%ipr Li4(g2j2�9 O/94L 1'honeit:_ q78 — y0/- 7e�o� .Irv)ou an voiployer:'Check the approprlute box: 'Type of pn1lect(nyufrtd): I.❑ I:un a employer with 4. Q I am a gcocnl contractor and 1 v Itpluyvvs(full andlurpurt-time).• have hired the.sub-conincturs 6. ❑Kew construction 2. 1 am a rule proprietor or Partner. listed un the attached sheet : 7• ❑ Remodeling +hip and have no empluyccs These sub-contractors have 8. ®Demoinion working for me in any capacity. workers' comp, instwnce. Igo workers'cum insurance 5. 9• Q DuiWing addition p. ❑ We are u corporation and its r,quirvd.) 'Wicers have oxervixcd III r 10.Q Electrical repairs or additions 3.❑ I uni a hiimeuwner Juing all work right of exemption per AIGL 11.❑Plumbing rcpairx or udditiory tnysclL Igo workeri comp, c. 152,3I(3),and we htrve no 12.❑Ruul'repain insurance required.) r ampluyccs.IKo workers ' comp, insurance ruquircd.1 13•Q Otller 'I I�mtnowoan why anon'his oRWauvir•iniliuri I r"l r r a lJuina ell Turk gold shottl iN wrside eu melon Mwi.uthmil a�n•w alf1davir imliurinx rwlr, •r,mtncrun thou elwxk Ohio Eon MULi anachod an addiritnal algal thuwine the panto of the rubrrmraaors and their wurkan'envy,pOdicy intbrmati . I am un enrplayer dwt 1.i pruvidin1l ivurkera'rurnprnmdon Ltturonce/br illy etnplayert Brlory 1a the polity und/ab ailo . h1forilludart Insuramv Con%pany .Name: Ihllicy M or Self-inst. Lic.n: --- -- . .. _ Expiration Date: Job Situ -lddreas: C'ity'slate/Zip: Attack it copy of Ihs workers'cumpvnsation policy declaration Pugs(showing the policy nutuber and cxplratlun date). Failure W secure coveruge as required under Scdiun 25A ul'JIGL c. 152 can lead to the imposition of criminal penalties of a rive up tu.S 1.500.0n andlur one-year imprisonment, as wC11 as civil Ixnahtes in the t'unn of a STOP WORK ORDER and a fine of up at i250.00 a Jay ,iguinat the violator. Ile advised(hut a copy of this slutemant may be 1'urwurdcd to the Ol'licc of Ilir�aligatlmts ul 111e DIA for nnurarcc covvragu tcrilicahun. I du Bert-sly certify under the rainy nd prrta/tl. . /'pro ury that the inf'urtnalb-i arvided above is rr srand correct �ica:m ra _ / ) � 2 -OflWill site only. Ov nor n•rdt in/hlr area, to be cuntpleted by city or rmvrt n//1ciuL i Of or 'I'otrn: _ Pcnnivl.lcense Y_ 1 1\auing Authurily (circlo one): I I. IIO,arJ of Ilvahh 2. Ihrildiuq Ucparuncnl I. I:i,)r'1'uwn Cie J. L•'lectricd luapccrur i. Plumbing Intyccrer I 6. QUivr l'�nuacl l'r nun: Phone tl: __ I 1 V Information and Instructions Nl:usachusetts L)cncral Laws chapter 152 requires all euyiloy°ion in the s to ervice of another ull,ler nny contract of h tor their ire. Pursuant to this matute, an rmplgrre is defined as"...every person express or implied.oral or written." lry \n employer Ic dctined as"an individual,Purmtrship,.Issoclatton,corporation or arse legal eCasYed or any two employer.orr the or more .r the (JreSoittg engaged in joint enterprise.and including the legal repfeYCI11a11vC!of a 1 deceased t eceiver or uuslee of.us individual, pxrmership,assoetalion or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartrnents and who resides therein,or the occupant el the dwelling huuse of another who employs thereto shrions to all not because of such construction mployment be war cel tok on �be an employer." or on the grounds or building appurtenant MGL chapter 152. §25C(6)also states thug"every state or local licensing agency had withhold the Issuance or renewal of a Iltemse or permit to operate a business or to eoestruet buildings In the commonwealth for any tpplleaal who has not produced acceptable evident@ of cumpllance with the Insurance coverage required." Additionally, SIGL chupter 152, a25C(7)states"Neither the commonwealth our any of its political subdivisions shall enter into any contract for the pertomtanct of public work until acceptable evidence ofconlpliwtce with the insurance requirements of this chapter have been presented to the contracting authority." Ayyllcants Please rill out the workers' compensation affidavit completely,by checking the bog withtheirhy to d"ifioates)of situation and - necessary, supply sub-contractor(s)name(s), address(ns)and phone numbers)along employees oth insurance. Limited Liability Companies(LLC)orworken'teompLimied abnsstion ility Partnerships insurance.(LLP)with o If an LLC orLLP does haveer than the members or partners, are not required to carry employees,a policy is required. Be advised that this alidavit may be submitmd to the Department of Industrial %ccidents for confirmation of insurance coverage. also be sure to slga and dale the aMdaviLnot Tlss affidavit should he reltmted to the city or town that ilia applicationatiafos regarding the law or the permit or or if q is ua am required g requested,to obtain a workers'Department of Industrial Accidents. Should you have any y ue compensation policy,Please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appro riuto Tina. Clry or'fowa Offlclsls avit is complete and printed legibly. The Department has provided u space at the bottom Please he.arc that the affid Of die affidavit for you to till out in the event the Otiice of Investigations has to contact you regarding the applicama I'I:asc be sure to till in the pr rnitflicense number which will be used as a reference number. In addition,an applicant drat mint submit multiple peonidlicense applications in any given year,need only submit one atiidnvit indicating current policy informati17f the necessary) ecessairds iryhut has been officially Ytsmite d under"Job ScpeJ or marrkedss"the lbyv 1 e city ore town l'nay be provided to they or Y P town)." \ coPY applicant as proof that a valid affidavit is on file for forum permits or licenses. A now affidavit irrupt he leech out each venture year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dug licence or permit to bum leaves Cie.)said person is NOT required to complete this affidavit. 1 he i)tiicc ui luvestigatiuns would like to thank you in advance for your cooperation and should you have:any quesuons, plca.e du nut hesitate to give us a call. fhe D:paruncnl's address, telephone and fats number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 'fee. ltl 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727.7749 Itr.ucd 5.'o ns www.m&w.gov/dia CITY OF S.U.&M, A-1SSACHUSETrs BCILDLVG DEPARTMENT 120 WASHLNGTON STRESC, 3i0 FLOOR ` 7-EL (978) 745-9595 FAX(978) 740-9M Kl.NtBERLEY DRISCOLL HUYOR THows ST.PtERas DIRECTOR OF PUBLIC PROPERTY/8MOLNG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit )$ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: ARE QT3?0SFj (name of hauler) The debris will be disposed of in (name of facility) FedpJJ-1 vn Nc� (a dreis of facility) signature of perm' applicant date dchnvdda