26 FOREST AVE - BUILDING INSPECTION (3) Daft l 7i 21
Y ploPwb Loomlod ti Lwaoioa of 2 Fare s1� .
l o wdoo OhIfCl1 YM��Ilo,� sau"m
M P"Nov taomd In
;• b OarM�On Anal Yam_No
B SaW PMff APPLwATM �
Permit to: �` Deck. Shall. Pad,
(Gr01e wtlidleYer apply) Red. Raroof.
PISPAWRSIWAS. 011ler'
PLEASE FILL OUT LENKY i COMPLETELY TO AVOID DELAYS N PROCBSSM
TO THE INSPECTOR OF BU LDING&
The undersigned herby apples for a permit to bLdld aaolawft to the bNWAp
oppoilloomm
Ownses Name
lie
Ad*m& Phone Wi 1 -711 — U rzl,l N
Ard*oW* Name
Address& Phorls . t I
Mechanics Norns M-etro ¢ otn-e env Orovem,6,,t . Ln d,•t, (611St- .
Address d Phons 6fA,1"9ree lG 171 (f2k
mo a v0 p.pm it U1IYfYIp7 rn l w�,�.� Vies,"dev.h
Lum"a a~ �a Pe Is - -lj for how sArY l "W? u. a-l' n w.<<
VON Odom oa, to Irw9 T Af/j�+-
Goam d om `�1 q�_ow uo f tJ A shw uof f CS
tJJI v" Lfe. / Soohn of
SXMW UNDER THE PENALTY
OF PWURY
DESCRIPTION OF WORT(TO BE DONE
MAIL PERMIT T0:
6�,9 I � I �-
No.
APPLICATION FOR
PE/RAfr TO
LOCATX)N ( 1
PEFWT GRANTED
Ia/ al tot-)2e
CITY OF SALEM9 MASSACHUSETTS
100 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTs 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildin¢ Department
Debris Dismal 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:
CIc�LG/Y) Gl/�Sle Se.rvICQS �/rC. (-)&-/J E3 - 7000
(Location of Facility)
Signature of Applicant
.a - al -
UT
Date
Ilse a,arntrvrrvcrs..s vJ .........��....��
DeparrMtrt ojlndu&Wd Aeddenta
Offla of Invesdgadoxs.
6" WM A:inaton bl red
Boston,MA 02111
wwWtnansawafls
Worker'Compensation Inanranee Affidavit:BWldemContndorsMecMdansi%mbers
n n Info Plisse Print LejiM t
COMAS
Name
Address 6 ►nl f I
01y/State
F11.
loyer?Chakd rappropride bo:: Type atproteet(regwvm:
I.alloye wish_j-- 4. 0 I am a SmWal aopeaa�and I 6. ❑New aasawtien
(mll and/or Pamthwl' have hired the sdb•eontiacbat 7. 0 Remodeling
pwpriew or paw- fimd on�'"a`had aheec= L ❑ Demolition no eophryees There sub-oonVaCM blue g for me in oar csg aMY wotkgs' W25L nmtianca, 9. 0 Boadini addition,
[ice ab ri&ofnempdooper
��,romP � S. 0 We are a corporation add is 10.0 EkeWW sepaits or additions
ofllaas have a mew tlseir
MGL or additions
3.0 I am aeowiter
bom doing an vwak 11.0 P)nmbini> sat
»YNK (No , camp. 0: 152,11(41 and webaveao 12.0 Roof repairs
wu=ce required.]f employes. INo Wallo t' 13.® Other 1 nS�vi y'^ � s °�i
i
COMP.imurana r«laiM&I
•AOY epptieet thr chtebboi rs MS do fig ad*A redo.WOW&Whin dMir watae'ereymrdm Potbr i vit meat *meh
l adi
t EiomwMwn vlto wthMdtab effi&vitrtina dwY se daft di wok md&m likemide a oouuacwnmM aib ¢ ,
rddMwd dad d maven the Omr oftir abeoMhe Mod em&we t w COMP poaar mfonvows.
aCeMMedolt�cheek Ms Ewe mut ettrked a
I anon cwplrye dint bPa
tvorkcrr'compcnardon bfvunorcc jor sty emPtoym dstow b dttPoHq/sal Job oily
al«wmdm M C
Insw=CC Ooa4amYNatna
2 0
Policy tl or Self-ins Lis1 S Expiration Dace / O/-2 5- 2 y a
Job site Addrett`
2 6 tMfe st AW Cayistawzip:
Attaeb a copy of the workera',eompaWton Ply declaration page(s►ovvlag the Polley number aM easlratlon daite)-
Fan=b secan cos oaye as required under section 25A of MGL o. 152 can lead to de imposition of criminal penalties of a
foe up to$1,500.00 and/or ono-year hWbomrieo<,an wel9 tip civil penuMee m&c form°of a STOP WORK ORDER and a floe
of up in$250.00 a day against the violow. Be advised&e a copy of this statement may be forwarded In the Office of
Investislik"ofdw DIA far maraca covaW veri&adon.
I At Army cony*under for and pcnatsia'�Parlawy tlYat nc�litfi►wofiois PivrviJsl above Is urns nrd arrvseit.
D
at®awra
OjkAd um w* Do nd wr&bI ebb Nv4 is Ar eefiVkard A1'ti0 orA mn ojkM
City or Tows: Persolmeene 0
laving Authority(circle one):
1.Board of Health L Building Department 3.Cityfrown Clerk 4.Elechieal InSim r 5-Plumbing Inspector
6.Other
CodaR Person: Phone S:
Massachusem General Laws Chaucer 152 requires all cruployets to provide woman' compensation far their employee.
Pursuant to this smw, an empbyw is dalned as"...every person in the service of another undo any contract of him, .
- express or implied,oral of wrbmw
An a~is defined as"ffi mdlYldYil.pamaa*umdg i %CWPw8nQI err other legal emft Of any two Or more
of the foregoing aWged is aJoW alwpjI4 and incle ft the lqd represaotatim of a deceased employer,or the
receiver air trtdte I aEtn n dividttsl,patuasbfp.asmoaiat m at other laud corny,a wbymg erpbyeas. Howeeer then
owner of a dwelling house bavmt rot mere tm throe aparaornat and who midei thaem,or the oavpad of the
dwelling hone of xmdkw who employs persons w do mamtewswA aonstmai a at repak w alt oa such dwelling home
cr oa the grounds or building tune'shall rot beanie of shah eopbymat be deemed b be m copl oy a."
MGL chapter 15$12SC(d)aim ststes that"every state or load reea ft ageaey dW wkhhdd the knoll"or
reaewd of a Ikease or permit to operate a badness or to eomserad balidlap In the eommoraweakh for aq
appoesM who bw ad prodwW seeeptahie evidence of eompllasce with the insurance coverage required
Additionally,MC,jL;chaptm 15Z W*C(T)status"Ncidw the oommonwalt nor any of id polidal sub&isiow.a>taII
ewer im my condad!ire the pafmana of public woik moil acceptable aidenee of compliance wild the itwunme
repirements of this chapter have been presawd to the counting serhorky"
Apptlesals
Please till out the wrorkets'compmsation atSd"ampletely,by ebootmi the bozo that apply to your situation and,if
may,supply aqh-oomuacbt(s)name(sj address(es)ad pbone numbers)along wit their certifiak(s)of
imusaoca.Limited LiabiIily Compmies.(LI.C)of Limited Liability Pameefbga(LJ-P)with no employees other dues the
members or paimas, are not required to carry wodwss'compensation immmoe. If m LL.0 or LLP does have
employees,a policy is required. Be advised that ibis affidavit may be submitted to the Dqw mre�of I ben iial
nts Accide fbr ecelfinnadas of insmuce wvaage. Also be sere to sip era/date the&Mdavk. The affidavit should
be weaned to the city or Gown that the application floe the pamit or lice=is being requested,ad to Department of
Isdnsuial Accidel.. Should you bave any gwxdom regarding the lsw or ifyos are required to obtain a workers,
oompensatioa jwtiLy,,pkaac aD the I)epa<bneat at tree n®ber listed below Self-imorad oom ==should earn their
self-ittstumce litxmsemmber ere te.aperoptiate lies
C14 or Town OfIIdali
Please be stun that the affidt vit is complete and printed kgfbly. The Departmest bw provided a spate at the bottom
of the affidavit for you to fin out in the event the Office of Imese gptions bus to comet yott regarding the applicant.
Please be sore to fifi in the pan&I&A me mamba which will be Hoed as a reference comber. In addidoq an applicmt
that mot submit muhiple pamit hmw applications m my given year need only submit one affidavit indicating anent
policy information(if necessary)ad under"Job Sire Addreaa"the applicant should wfffe"all locations in (c*or
town}"A copy ofher affidsrit dkg hat boa oP&islly stamped or.merked by the,city or town may be provided b to
applied err proof brat a valid affidavit k on,>fle for fltstre permits or licenses. A new affidavit emst be tilted oat each
yea.Whore a borne owner or cidm is obau f&liceme or permit not related so nay business or aommenciel ventum
(i&a dog license or permit b bum leaves eon:)said pesos is NOT required do Campine this affidavit
The Offia of Imrcatigsdom would MW to d mk you in advance for your coopastion and should you have any quesdoaa,.
pkaae do i otptaitale'*give u a all.
The Department's address,tekpbone and hz number
The Commonwealth of Massachose to
Department of Industrial Acmdenta
Offta of Inve ldptim
600 washmgtan Strut
Bostam.MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2"5 www.mass.gov/dia
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts NCCI NO 26158
(800) 876-2765
POLICY NO. AWC 7020033012005
PRIOR NO. I NEW BUSINESS
ITEM
i. The Insured Chun Hu dba Metro Home Improvement Co
Mailing Address: 16 Williams Court Braintree
MA 02184
(No. street
Town or CitY County state zip Code
FEIN 13-5923451
® Individual ❑ Partnership [I Corporation [I Other
Other workplaces rat shown above:
2. ThepoficYPeri0disfrOm
1012512005 to 10125/2006 12:o1 a.m.standard firm at the insured's mailing address.
A.
3. A. Workers Compensation Insurance: Fart One of the policy applies to the Workers Compensation Law of the states listed here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
500,000 oli limit
Bodily Injury by Disease $ 100,000 eachemployee
Bodily Injury by Disease $ -
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below is subject to verification and change by audit.
Premium Iasi$ Rates
Classifications
Estimated Per$100 Estimated
Cade Total Annual of Mnual
NO. Remuneration Remuneration Premium
INTRA 011810
SEE EXT NSION OF INFORI IATION PAGE
Total Estimated Annual Premium $ 975.00
Minimum premium$ 500.00
Deposit Premium $ 1.005.00
As indicated,interim adjustments of premium shall be made:
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg.
$688.00 x 4.4000% $30.00
11101t2005
This policy,including all endorsements,is hereby countersigned by rwmarrsed sigaamre Date
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP L C International New England
MA 5437 2 704 299 Ballardvale Street
WC 00 00 01 A(11-88) Wilmington,MA 01887
Indudes copyrighted material of the Motional Council w Compensation Insurance.
used wth d5 penr44 iw
LANDING CONSTRUCTION
New Construction/Customer Design Remodeling, Kitchen, Bathroom,
Window, Siding, Roof, Basement..........
On-Site Assessment, Reasonable Fee. Registered Mass. Contractor
Financing / Mortgage Available
523 Pleasant St. Apt. 1, Malden, MA 02148
Tel.: 617-669-7771 ♦ 781-888-6777 ♦ 617-257-2811
Email:easylinemortgage @ aol.com
(w�q�a��rjr�46�
Customer: f7ib� PaKG�e ,�QC l nv�i'I 6/�f 23 I 2f2a 010/
Address:
Telephone: C q
Job Done at: ��F UY`P�fi e a � I�1� Date-
Description Amount
Roof _ c�
Siding kv
jack
Kitchen
Bathroom
Basement
Sub Total
Tax
Total
Deposit 4Zp00 ►S} a6t
Balance An o
Thanks for Your Business