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16 DEARBORN - BUILDING PERMIT APP No. O� AP.PLICA ION FOR ' PERM TO LOCATION PEqMIT GRANTED --• ' —� As ;?,go� APPROV&FcTon D p L OF BUI INGS m CERTIFICATE OF OCCUPANCY - YES —. .s' 1. .�. � .. • The Commonwealth of Massachusetts l Department of Industrial Accidents fib V Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leetbly Name(Business/Organization/Individual): _ A j&-,r via S -Tn Address: I I ri Q or+h 5irc e+ City/State/Zip:_5a p M M iEl of'770 Phone #: / cn F u an employer?Check the appropriate box: F[:] Demolition ct(required):I am a employer with� 4. ❑ I am a general contractor and Iemployees(full and/or part-time).• have hired the sub-contractorsnstructionI am a sole proprietor or partner- listed on the attached sheet. t ling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance.No workers' com addition [ p. insurance 5. � We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself. [No workers'camp. c. 152, §1(4),and we have no 12,0 Roof repairs insurance required.] t employees. [No workers' ' comp.insurance required.] 13•tr Z Other]6&yy,1QpVS *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contmctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infomtation. I am an employer that is providing workers'compensation insurance far my employees: Below is the policy and job site information. r�- Insurance Company Name: I y`e— Tra V0 It Kn Policy#or Self-ins.Lic. #: �Ai C9 3q X I Expiration Date:_9 i3) 0_7 Job Site Address: I_ ✓.ram cn- i�lrto cj jtka City/State/Zip:' P2,9 Dl9 o Attach a co of the workers' 7 PY 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. fditereby certify d r the pains andpenalties of perjury that the information provided above is true and correct. re: Phone#: k4 oZ H FF l use only. Do not write in this.area,to be c=bycilyfficial Town: Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r t Person: Phone# DATE: r �ifp Dfar�m, aaLjuEff PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Building Permit Application For: Location of Building 6 Leal-born 6MPei4oZ -- `(Circle whichever applies) Roof, Reroof tct Deck, Shed, Pool Additio Alte a air/Replace, oundation Only, Wrecking Other: PLEASE FELL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Bttildings: The undersigned hereby applies for a permit to build according to the following specifications: Owners Name: )-Irdo Noon Contractor: A eA 6e-rVI%,e5'('hnt> t9r7 Street ILO be0f'hz) -1g 9. City cS-j�Piv, sveet-1l 5 Nnr}h S� Cit3-,,�l State, MA Phone (gqg)_7y1_ t/gs y State M R Phone. (Q78) Architect: City of Salem Lic# I W o5 Street City State Lic (757 IEIP# ©l(0 09 State Phone ( ) Homeowners Exempt Form_yes,,4/Xno Structure: (please circle) Single Famil , Multi Family# Other Estimated Cost of job S_ 6, 0$ Will building confirm to law? yes no Asbestos?_yes_I// no Description of work to be done: r�sfall s even l 7 ) VJ rP yla ce c )11-\d6W5 A&A SERVICES,INC. Drawings bmitted:_yes no Mail Permit to: 115 NOR IMA TREE Signature of Applica 'on,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE