011B FILLMORE ROAD - BPA-437j"V*E fKfi9 W APPROVED BY TiWE
1mQP,,ff= B PBWR TDA.PERAfff AEWG GRANTED
CITY OF SALEM
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BIALDING PERWT APPILIM ON FOR:
Permit to:
Circle whiohetrar apply) Roof Reroof, Instal Sidlrtp, Cortetruct Shed. POOL
floe.
PLEASE FLLL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF BUILDINGS.
The wldorsgwd hereby applies for a permit to build acoordinp to the idbwmg
specilicaboric
Owner's Name G u I o h Sa r5 e
Address & Phone
Archdect's Name
Address & Phone j 1
Mechanics Name 2 o beA t J. e u r-e_u
Address & Phone F- /-8 /-fot/: Lv 9 5)
Whit is to puposa ai buiWq? Z)e
ftA W a btlYdirlp? PT, I a dws*ig,for how mmy Wnba4
WE bA*g CM#W tl to Iaw7 Ye S Asbo"? N °
Erim coat Z o o cfy ucaw N/A- gpr u.r CS 0/$ 3 2rb
Sipnatua o Applicant
SW = UNDER THE PENALTY
OF PERJURY
DESCuvnON OF WORK! TO BE DONE
l P- r oYC CL,C-
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MAIL PERMIT TO:
I -8 W7
No. _
fAPPLICATION
FOR
PERMR'
TO
LOCATIONPERMITGRANTED
4
2.
0
INSPECTOR
OF
BUILDINGS
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1
CITY OF SALEM9 MASSACHUSETTS
3Elm 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:
X3 e r ,s '1 e C' Location of/Facility) Sc"
Signature o Applicant
ll - b 3—
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www tnassgov/dla
Workers' Compensation Insurance Affidavit: Bnilders/Contractors/Elep idease Print Lep-iblumber v
Anylicant Information
timn'd vid"iName (BasimslOrBatiza
Address: 8 hl a l-'-
Phone#:
City/State/Zip:
box: Type of project(required):
pre you a0 employer?Check the appropriate4. I am a general contractor and I
1.[] I am a employer with 6. New construction
e have hired the sub-contractors
employees(fill and/or part tMle).
listed on the attached sheet t 7. Remodeling
2. I am a sole proprietor or partner-
These sub-contractors have 8. Demolition
ship and have no employees
workers' comp. insurance. 9• Building addition
working for me in any capacity
5 We are a corporation and its
comp.insurance Electrical repairs or additions
o workers' co
requaed•]
officers have exercised rhea
LIZE]
lumbing repass or additions
3. I am a homeowner doing all work right of exemption per MGL
c. 152,§1(4),and we have no oof repairs
myself. [No worker COMP.
employees. [No workers' 2e L w sinalrrancerequired•)t Other olo 1`j
comp.insurance required.]
box#I must also 511 out the section below showing their all compensation policy infatmmion: Any applicant tint checks
sting,am doing all work and then him outside conhaetots must submit a new affidavit indicating such.t Homeownem who submit this at&dstContacsomgotcheckthisboxmust attached an additional sb ect showing the name of the subconhaclms and their wotken'comp•policy information.
I ant an employer that is providing workers'compensation insurance for my employees. Below it the policy andJob site
informatioe.
Insurance Company Name:
Policy#or Self-ins.Lia #:
Expiration Date:
Job Site Address:
City/StatefLip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Falil=to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of afrneupto$1,500.00 and/or onayear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fineofupto$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 and penalties ofperjury that the information provided above is true and Correct,
y I /Date• D3 -O o'
S
ojk'W use o,rlls Do not wrla in thly area,to be completed by city or town odleial
City or Town:
Per•mimicense#
Issuing Authority(circle out):1.Board of Health 2.Building Department 3.Cltyifowu Clem 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone#:
1111V1 lilKevlVll KlaY .1110 a.1 YVl1Vil 7
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtim"
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,ad including the legal representatives of a deceased employer,or the
receiver or.trustee of an individual,partnership,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 agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the com sonweahh for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152, §25C(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 coutiactirrg authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(sl addresses)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies.(LLC)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 resumed 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 die Department at the number listed below. Self-insured companies should enter their
self-insurance license munber on the%ptopmiate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has.provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permidlicense number which will be used as a reference number. In addition an
ticense applications m an
applicant
that must submit multiple permit app y given year;need only submit one affidavit indicating current
policy inform(if necessary)and under"lob Site Address"the applicant should write"all locations 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 die
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 titian is obtaining a license or permit not related to any business or commercial venture
i.e. 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 W 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2 05
www.mass.gov/dia
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