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3 GREEN LEDGE RD - BUILDING INSPECTIONr D -y _O .o v - m A Q _ a S Ia o , z on CW ��ldkrvk'����i►iti� .�.a .. ,.��,:�kl �,:, �, u�tw>�.is�.��rix�.�tr�+pr�►i�l,'i��wFrrn'I+a:�' . f ;�y,►rc•�.ut;:l!?RN1►Nr�w!' ).E. •w'�ri !rst=yar+p}, fli Y 1 t �r{., W .. ".I�YtM,�...•. I, F,fr.zibi urr�,. .: t :r, ryMrKt,i rih;p .._ ._. Q_.II U'LRa{OI if,. ;..,;tr-f:!11j'jp..' ,�ai.tw . 'F�"K. :O,, - ., . .. . ,,;auF: -•,:IYI"(ry,rlVlshi --K7L:14�1'p11fH it ;Wr•' ;q., . i�; �h ALB; �. d1i.r�C• �1'•'f(� •t - y.-.a7k ....11'y:... i::P n«ti lA2Re:... ..tffl7. , ,,r.'•tiFi • "4JM1' ,. 31LN W4. \MX.', f•.+ ?::I:,Y ,[*..,:k�,+ C! �'K•.G� �SAYi.4:'r'� I M. iN''• :k•*noV 0 �j• iy+ 1% .E11`` Y; tl+t ' .,t. ,. '•� ;:tQf691 +:1�$�f/iE:'14?�d'Lii.iAl,V • �.,' °a .ti>t yd 4�C.1 7):t: >iYF'; r� 'P:{n f'j�ilf�Yi':*�.ta �ii ���1`, it ' MV.1• JIM: DfarEm, a��at�ju�ES PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BZING GRANTED Location at Bailding G► ten, Building Ptrdt AppBestioo For. c f m ICircle whidwm applies) Root Romf.. Install S xx Deck.Shod,Pool Addition, AlwKio paidRaplaoe. ouaduion Only.Wrod"S PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROMSING To the hoPector of Bui diojs: The wW m *"Itaeby applies for a permit to build accordu g to the fallowing apetdSatiens OweeftN ,,,J,;`,�,,ri/,nc Contractor. _1 nkj& Street G eP n .�a o C city '1 Strea���gaL,2(�Chy '2 Sate.QL S Phone c 975)j((4(-79� C mot /j).- Ph000 ArddWl•- /V ` City d SohnLie�. Street_ City \ State UaM DS/n/ w M Ids State '-\ Phone ) How"wom Etteupt Fona�es a0 MMKM1 e: (please circle) Single Family. Multi Family#L- .011M l6c 4 / Ti.ati.attd Coat of job SI C4�1 )4100d2 c5 Wig kdhMg comics ic larr! s no Asbtaud____yes v_tto n , Deacriptiaa of wont b be daae:�n ja e l e Xr /n n•Y' fi D,QJ � II /Ohl � Int�ILh{Pl)n�� /1 [��t�hF// aim 1')(�(tP�I� rercD . V�{La[3Ar e Drawing Submitted: L/ no Mail Persil to: Ap S GNED UNDER THE PENALTY OF PEB.IURY CON UCTION TO B 6MPLETED WITHIN SIX MONTaS OF PERMI T ISSUED DATE DcPgn=WA use only: Perr*# Zo*g T Permit fee i commms: . CITY OR SALCM9 MASSACHUSKTTS i's PUOUC PnoprLnw DEPAnrmENT 120 W"HINOTON aT mm. San FUMN aALSM.MA OI 070 TaL. (/70)749-MOD 9n. 300 FAX (078) 740•11040 STANLir J. UaOVN:i. AL MATOa DISFOSAL OF DEttRIS AFFIDAVIT In mordam with the Ploviaioos of MM c 406 M I ae]movAWV that m a wafi m ofz remit F an dd&muft fines the oos s wdm wdvhy Vvmd by this DwIftFae»lit aMl be dbpmed offs a properly Hemeed solld-waata disposal&ditq as defies d by MM a UL 8130& lU dd &wilt be dfspoeed otme 3 �r�. �� h �t/ Ia�haa a�tPaeility 7- 30 - 0 5 Sig Mums of rams ANUM - Die FULLY complaq the fotla"mform ftm (PLEASE PRIM CLEARED Name of ran*AnHeaot Fin Namk if my psIj9u _ ��u m Psi r7 Aht M I D AdMak city R Stan The above Mute r%wn that debris Am the demofitiM renovation, rehab of ostler alteration of building or*wan be disposed in a pmpaly-licensed so"waate disposal &C ty as de6sed by M(1L CIA S 15K and the building pamits or lieensw m to mdate the beadw of the facility. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dle Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businesstorgamratimindividual): Address: n City/State/Zip: C,2,n ro A±� Phone#: 7V 5 Q 7 S 4/ Are you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with Off' I 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheeL t 7. © Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an ac workers' comp. insurance Y capacity. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its - required.] officers have exercised their MCI Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I-El Plumbing repairs or additions myself. [No workers' comp. a 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.(`Other comp. insurance required.] *Any applicant that chedke box#1 must oleo fill out the section below showing their workers'corttpenestian policy mfmm shim' t Homeowners who submit One affidavit indicating they=doing all work and than line outaide contractors must submit a low aflidsvit indicating such tConmictons that check this box most attached an additional sheet showing the name of the sub-cmifter n and their workers'comp.policy information. I am an employer that Is providing workers'compensation Insurance for my employees. Below it the policy and job site Information. Insurance Company Name: ao_Mi t if Policy#or Self-ins.Lin. #: 0 2a7( : I Expiration Date: -—/O s O.S Job Site Addrcss: ,_ 6,-A Jo, q O. S�. City/Stateflip:��20,f� . Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Farhuo 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 S1,500.00 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 under the pains and penahks ofperlury that the information provided above Lr true and correct Si Lure: Date: D S Phone* 00kial use only. Do not wrfte in this area,to be completed by city or town q f4eidl. City or Town: PermitlUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ifif V- ---^--- - - - r vide w I orkers' Compensation for their Massachusetts General Laws cbapter 152 requires all employers the service of another under any contractlob. Pursuant to this statute, an enyd fee is defined as"...every Person express or implied oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing eagagod in a joint enterprise,and including the legal representatives to i deemplocAcascd employer, v the receiver or trustee of an individual,Partnership,association or other legal entity,employing employees However the than three apartments and who resides therein,or the occupant of the owner of a dwelling house having not more dwelling house of another who employs persons to do mamtemanco,construction or repair work on such dwelling lease or on the grounds or building appurtenant thereto shall not because of such employment be deemed Lobe an employer." MGL chapter 152,425C(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 Is the Commonwealth for any applicant who has not produced acceptable evidence of compliance with the Inanrance coverage required. C(7)states"Neither the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152,§25 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 contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the box thatlyy YO S tion and,if certificate(s)of necessary,supply sub-comractom(s)name(s),address(es)and Phone number(s)along insurance. Limited Liability Companies(LLC)or Limited Liability Pammerships(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 retained 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 the Department at the:number listed below. Self-insured companies should enter dteir self-insurance license number on the to line. City or Town Official 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 permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given Year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner of citizen 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 as a call The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents OfSce of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia