11 FREEMAN RD - BUILDING INSPECTION ��NS�Atl�T7EfNsSDd1Np A,PPIgVED 8Y�iiE
ANUUM PWR TD A.P9 Wr SLEW QRANTkD
CITY OF SALEM
MMa
,_
Zor&q oldna
b l?
►M H an Dko in Yu-No 1"ation of
Is Amoy Lamm in
f'anni<to: U W X4 PEWW APPUCATM PM
(l kola wfwhaMar appy) P4dj Ramof, I WW
W Do* SMd. /Pool, a�
PLEAS!RL OUT WOWLY i COYPLEf ELY TO AVOID DELAYS IN PROC UMn
TO THE INSPECTOR OF E UILDINf3S: '.
hwnby apOn for a parmk to WW aooad ft•o Mn toMowNq
Ownara Name Z 4/m es -t,
AMh*Wo Name _/t/cr kA--4
Addrm A Phone iy ci w f f
MOO*nia Name Att14Aroti L,-,Ll41
Ad*M A Pha» _94dV,,: /ft/ ` 2-7 —7.2- 4)
whr K on prpM a/bir'bl W
kftftod d hdmq m 4.v e-cl N a diMaiq,for how aap r trhaot4 B Ale
MIN kd"ooerN %Mw Aft~
Edki"=d D orry Or Lk o 1, J aft LIarIM•p�S Q2 Z
1 5;lAe SIN= UNOB1 TM Pw"TY'
OP PfaR1URY
oEscRlvnoN oP woRa To sE DONE
MAIL Pmm TO:=_�
f
APPUUTM F
PEINW TO
LO"T"
/J f:;aelv,� Rom/
19
�� �
INSPECTOR OF eAWNGS
ueparritserrs of inaWsrrw nectaenrs
` OF"ofinwi ofsadons
9 6" WosiJnston&red
Boston,MA 02111
tvwwasi sewas
Workers'Compensation Insurance Affidavit: Builders/Contnctors/Elecbidamwnnmber>s
Applicant Int
Name aG�t✓z��/ ice �WiSLfG�u /k��
K
Adis e e ,wAm�
City/S>ate/Zipc ¢lam Phone 0: 5 al�ilr
27 23d
Are you an eMkW CYeeh the appropriate bw
1.p I an es4bye with 4. p I sm a praad contractor and 1 Type of Project(required):
_ erpbyaa(afn and/or pats-tim** have was the ale ooatrapora 6. ❑New oanttracoos
2.[a'I am a sole proprietor Wwar Bated an the attached that t 7. �tmodeliop
S*and have so empkryea These sub-contractws have S. p Demolition
working fix me in any capacigr. workaa'con4•iyman d
[No wadmo ad*invorsuce S. ❑ We are a cmporstia add ill 9. ❑ RaildiaL addition
rwait 1 i ofikw have cracised their 10.p Electrical repairs or addition
3.❑ I am a bomeowndr doing an work right cfesen*"per MGL 11.13 Plumbing repairs or addidow
Myself[No vakets' comp. a 15Z 11(41 and we have no 12.p Roof repairs
inaoraooe r� I t i 13.0 O&a
;Any appnw tut chocks Loa I#1 aunt dw®outdo.xtim edov aowbd teak watbam'
t aomeowo=who mama Gb aBidsv* a policy iobamdoa
tCmasio,m t6a cbxt 1hL tau moat r0orbe iddkiondd about�wakand aim bim oaW&conhacton mot m*o*a now afBdtvit od;catina mach
danhq err nos ofth wbe nhadW and ink woe"o'oc„q,voft halbrmatloo.
Iax
swpioya r1Fer b prov1 rvor4en'enmpewa�atOa asrrrsneaJp a!'e+rrPJOyea� aelow b des paBgwslJob aft
rnemanoe Oompssy Name: �y/,®of1-,¢-j(e �/p.s r r nJ /'/ti s
PObcY d or SeWmt.Lic.N: ✓ Expiration Dare
Job Site Adduce:_// ! /Z�2 P�l/,�l�c. 2G� �,���:
Attach a copy of the workers'compeesailon Pitney declaration Page(showing the Paley number and expiration date).
Failure to secure cwienp as required under Session 25A of MGL c. 152 can lead m the imposition oftxro®al penalties of a
ilee uP am$1,500.00 and/or onpYcw impriaoumeut,at well a civil pmahies in the form of a STOP WORK ORDER and a tine
of up to WO-00 a day against the violmr. Be advised that a copy of this$Wcmcnt may be firwadad to the Ofte of
Im Ordilt oe s of the DIA for insurance coverage vatApoloa.
I di hdnb ev*UnA r ai&a&dw and orynry rbdr fir&laforw&rba puv1*d&bow b nw and awti!ea
d�
00kid rw oa(p. Do not wrB&in A&an&,to b&cowffl t 6j CD'err roan ohwd
City or Tows: Fwmfuueare 0
Isming Authority(cirek one):
1.Board of Heakk L Building Department 3.Cityfrows Clerk 4.Electric*!Inspector S.Plumbing Inspector 6.Other
Contact Person. Phone 0.
ter 152 m pims all Cn Vloytaa b psovide wotkM. tier Um"
�."r...�•••
Pursuant
s ant 10 as General Laws chap " io the savim of aaodka under any conuact of bore. ,
Pruauwt b this stains. �e"'��is defined a ...every Person
ere MPUA oral at wtttoea any
� asSoeiation.oorPontioa a other h�„al entity,at two or m3se
An ampwys is defiedas a as individual.P bf1>� tiNa of a deceased enployer.or tits►
ms"o is a joins eomespr s4 and i
of the forttoiet aaoeiatioa or other keel eaoStY,emplayle[emPiaYeaa
receiver err mutes of ass p mnb ' wbo taida thereo,09 is oeotptM of**
bouse
owner of a dwellmi bona'9 2" P�De b do mamtenaeioe.oo of TV*we*ere meh dwellft
rd boum Of pteuoda awdm mbw7dist apparte>vet laab'Un ant tee. a of a neh a Vloytom deemed dmed b be a amPUYW»
u
MOL�1A 4��aL0 states hat 0"'y dde"t weal twalsai s{�7'rht"kYroN the�°f
tht cOMansamweaft for a"
renewal of a Ikem or Vamp to operate a a f �v ases eon ro9dred o
APPROM Addiuosally.M L cbsVoeR in.4� "Neils the commonwea*>na a�oiid polidal
of psbh4 wort until awmubk evdeace of oosoplinam wi the roam en
enter tuna any eaauact d e per ttmatx b is oosetac anlositY"
vwkcments of this chap
APPlicemb le bona that apply b yam situation and.if
I fill out &t •can VensatIm affidxm c=Vl te]y.by cbeoluni wah their eati9caoe()
Please a and �( a of
nay.Sappb�ems)name(ab sddtas( ) ab°n° Pumaaatapa Up)with no emrploym
other nisi the
�acs. Limised LiabOW ComP�e(lam m Limited LiabfiltY ttmtrattoa If a 1 LC or LLY does bave
mew or P not b castY workers oomptti0e
employees,a )Oft is requited. Be advised that tier affidav&may be submitted b the De davL t of affidu it
cmeraps. Also be sve to dp rid date the dfidavk. The af3ds�'h ahld
of
bAccidents e w d n the �Or 10 &C application lr le P bag 69� �sot to Dep>�
Sb vM you have a"Vatican reptdi>ti b abtaia a workers'
Industrial A afi the Dept�smteat A S4 fund below Set[-inm cd a m pt�ahonld a thdr
compensam`Po M P Hie
seK-insnramee>lame>to>�d1�
CHI a Town 011klaM sift bottom
u conVklc and printed h�dy. The Depatttnaat bas Domed a a� �e
please be Sore let the aSidavit' tiou bas b contact You tepdiei le spP
of the affidavit far You 10 fll out in the event die Mee of ItmeSdVa In additiau.an appt�
please be sme b fli in the panMkcnse mm�ba whteh wM be used a a refamce mmber• mdicatuni cogent
aPP is any given yew,need only submit one afHdsvt �
ftt�icy mf sul:o ffi e u mdu"Job Ste Address"the apPhcaot Shaaid write"all locations m (C*
be Wovided to dw
roan}"A copy offs alb dt has boo o�SumPod or
A orb out each
apPHeaat 0 proof let a valid affidavit it tit file for(roue Pew not rdated to any business air cammacial venoue
year.Where a boors owner a!eitiam is abtamar[a Uccros or P
amit(ie a dap htxose err Pam'b bast lava etc.)said paean is NOT mquued Ineomplese lie afi'M* t
would hie b thank you in advance fa yam cooperation and sbmV you have any quamts ta.
The Office of Imestiiati°°s Pkaee do not hcdm V Jive is•cad.
The Darouem's W&Wsl tekanepb and
eP fm number
The Commouweahh of MassachusdW
Dept MCM of lndusbW Amdeab
Of1kc of Invesdptfo=
600 washmgcon Steed
Boaters",MA 02111
TeL #617-727-4900 ext 406" 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2605 www.mm.gov/dia
CITY OF 3ALZUS MASSACl USZTTS
PurlUC POOPOW 09PARTM[NT
120 VA%fti elm STamm. alto/I M0
SALSM.MA eN*7e1
TRL (070)749-eEM tn. 300
Is 'AR (978)74&""
STAMLa T A UII VICZ. JIL
MAMIN
DL4PO "OF DEEM AFMAVfR
Ill -mil I w6t tba poovfe M of]IM a 44 SX I a*wwWp rive a s CM&dM
ofM teE r etie r AN weds, U ft Set i.GOW00"ndvdy
SNSMMbyd&ftdftP dM be dhpm d offs a prVuly Ne+meed eolidwaw
duper!Soft,r dodud by idclt.a ig,SI Lf`
'Ibe debda wr7l b•dirpoead ofat: �l �2 e�,.�,�-�
Lam"ofPadNq `7
G� 2
S*m"ofPeemit Anlfeft
FULLY oamptw the hmmfrq m6 molow
MIA=PRWP CL WMV)
Name of Pismie AppNeaee
Firs Nan %if air
/ d .r C
Ad* a%Crry At AM
Thl Abow,ta Af@gwm dve debcie fts d,t demoliuM rmov kuM r"or otter
ileatdoet otbwl&g or Mroc M be d qued is a propatf-kmwW sou&waw d4o><al
hck>r de6aed by MOB. S1
� say and tiw
build parmitr ar lieeneee stf ro
wdkM td loeadw of& ' .