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1-13 FREEDOM HOLW - BUILDING INSPECTION l� Y I F d a 2 s ESA fF f 5 ty , I�UB�LICvOP" Olt ., �. ¢n tias uS 'Y a`ISw r' a F a g "'W71 + F� 'L300�wtNtu�1+�N�!'nP� It S 5 1 g f SAY WIE iLcc�Ho19 Nand' Build(ny," "fi "+ x Y �;` 'r, _ �Y hlYbcafed in a.Coheervatlon Aroa YIN Hbmric Obfrki 1�IN, , ry h Name. Nt r'Ti t+r(_._ ~ L ✓1'� yY r su, a A }35 - a� + ; HI S (� ON'(faR MI RKdllfr =9UI Aft'";bN�r // "w mill,l R Jari fn Uaitt _ . NeW s fr'" 0,1 ��ux{ t r'ad ��2}�' r a„a�-� ��{Or"�n04atlp►rlx�-.,- a s - � f s i� � � ^„y-. `� rY a » afi©nPrfJi0�5 � QGiE r , i � 1X3 " £ `'� � � ;' J" ^ "'a+ak r *'' .+i�j' / ,/ �,S<: F id r ;'� a7',''•'h a i�7gt s iPk^`4i } W MSI- gwr W � x �d,.. MEMO I uq �. { % z tY,i44L"ui�r�„I �r e 5� r t aza- .ts 5 ""^ z a>• a s #K, "°�s,;>r �.+� �tfOtito�"dm rm+W6aw'i"` --:r•� .�^'^,- /4Sbes'tC's! z�' z: .�t�' ;fX. 1, fic � a+. Y3 1 x �� p. ✓ .d hF axC7t"' z� fi i• by ✓ ''a' Ay � y wiz �HIC`�te�isi►$tki�li� >'!v6 �t Z S �Y u+vu-'`�'`,c��/`� F ��app� y } h Eat�ITlated=C3oit X S7111~y0o0 Reakfdnt�� d 4A d'� � 1 5 � * �Adifiib�sative eG 1412 lz E �,l�illtdurd that aU<fleiltls drs poperjy aril leyib writFen,to avoiQ delays In processin � w4 h����rYde ltlned does he ebY apply for_a�Suildi ertr�—It""thloundrUp,the abdv a �,? b Y� �y 5 �' ,/ tl u "� ,r � '�..✓ F, � - r + i ? t �rt {" ws� 5*e"^e�, b x x. d� t. lr af �� ��tt `�i� xuild4► naitY CY' 6Jf lj ` ' v ' " a "x r�AF ' Y� ; t�. r r Cci+'W4��1nnr„o-o-`hMd' C f �s C ^' ,�, M r} T k SDate�.�J��CI, "' . �"�s ':.'E..s�:t��j'emsFj.hrx gr t ✓ 4 r2 a s i b t a Cl9 4f u{' g°A[ei ' si'fi�2 }`cmt x _ c ce✓��1r >3sat* JiA.��.�' s{ �n ''k ¢4'? a4' r "-�'�f a �`ss @ a ",1aa � n� °' wid w✓3 3".c` �"�'eyz ti, o I ° �I ak{.y A��;� i' b tx$fi-ti f.' ��' �zciai/{'fie yR �F a' x - S `✓tt#A�� '�fr F41's�lC� xei 'F'� )'vrt, t ' °. ,? .� >•^ €*,y'r t qs ape z "^`fi4 I,c.>£ yr act{z r '� as• a R '� ,f x�'"4. - Y �.y + dwr,� 41 :C ' `➢ e��.' s ? 'b': M dbf'f bib 1 t. ;< 5 r�`Q� � i - � ki;k 1✓"-Y t { y1 t sue„ f W `- k;xt�Y "�+h�-�'w.tik�Y � frvl�dp' k`?s�#'�J�ti• a "7 `. 4 a ib�`s R t a� � a ir` k h ���t� ��n `i'^, a i- r>yp� x+`r'xayfir5,1 x,." r Tk,� `^ c b g-' vnN sek r- �a ''✓k.' 4 5 -'x t z.rt. „Y �h ,fiia .,>e E`•'-;c'Y,. zt4,v P z -: ,�pp The Comntonweglth of Massachusetts ' Department of Industrial Accidents Office of Investigations vi 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / {� Please Print Legibly Name (Business/Organization/Individual): `l rl ��er /tVC, Address: �_ 4 /P�`/f w a L Z�_ City/State/Zip: �/�'1 „�/�- Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with�— 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: 46— �3 75- (Y Policy#or Self-ins. Lic. #: /0 O / z Expiration Date: c r Job Site Address: City/State/Zip:S%/�i,.�w✓, l Attach a copy of the workers' 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. I do hereby certify u]En!z ,�--8L ' ofp u that the information provided above ' true a d correct Signature: _ Date: b Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk.-4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: CITY OF SALEM PUBLIC PROPRERTY DEPARTM- ENT Ttt:vn745.05" .F..x:O M74t:ys44 Construction Debris Disposai Affidavit (required rot all demolition aml renovation work) In accordance with the sixth edition of the State Building Code, 790 CNIR section 111.5 Debris, and the provisions of MGL c 40,S 54; Building Permit 0 _ . _ is issued with the condition that the debris resulting fmm this work shall be disposed of in a properly licensed waste disposal facility as defined by .MGL c 111, S 150A. The debris will be transported by: pmma of hauler) ----� The debris will be disposed of in nl:,ft,c, iaaIiIty) /J — S