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60 GROVE ST - BUILDING INSPECTION (2)
7 What a torlYrert use 0/the Bwlding it dwelling.how many unae4 m.ww of Bu~ �I� I Ambealmr we ew ButldM i Contbnn to LM4 ArcnillOCs Nam' � t Addnaa and PhOrA N F MedwWO Nara' Address and Phew ��3__ Ci 3 H- CorAWucon guparviaas Lkanse d O S'9 7l�3 HiC d s E�atsd Coat of Project 'U ✓' Ferns Fee Caitxdalbn 1�i o Estlmatad Coat X 87/i1000 Residential Permit Fee i�- Esdtnatad Cost X i11/i1006 ComnMdal An Additional 1600 is added as an Make sure that aq fields are Properly and ably"'ten to avoid delays in Wocaaing. fro / old The wows fined does hereby M*tar a Building Parma to build to the above stated ' O sPe, Signed under parway of Perjury Date %O-Ito •-O 1 0 s , i •� l as a 5n `1 � • O � � � '1 1 { `sm 1 a 1 4� 0 C1TY OF SALEM PUBLIC PROPRERTY .�1�01 DEPARTMENT �ltu a lDC r.m IN::JI►S ZEST�i�t:t1.ltAvttt:u.ts/1 s::a Tb:YONif'�!f •FA7C 97/J�p+leK Construction Debris Disposstf Affidavit (required for all 4enw4tion and renovatioa work) In wcordan a with the sixth edition of the Stow lb--W ns Coder 7SO C R section 111.3 Debris,and the provisions of\IGL a 40.S A S W Iding pannit A _ I _ is lama with the condition that the debris resulting f am this wort shall be disposed of in a property licensed waste disposal facility as defined by\1GL e 111. S 30A. The,debris will be transported by: taaoe M haWdO rho&-bds will bo disposed of in : 1 u.me ut facdlty) V N SL_�vf/YTT .�J.:rmb ai Yx a.tyt . .Ad CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT MUM Rif Y URM-1)" MAYOR 12C WASka.%C.'rota SnttaT a$Ault.W.sslAcl n aT.'I'r\0197,^. ThL 978-743-9595 a FAX:97V-740.9946 Workers' Compensation Insurance Affidavit: Buildeers/Contractors/Electricians/Plumben analicant Information Q� Please Print Leoibly Name tousincswv)tpaizwiotvinJividaal): A 9,le /ayfi/�,y�1C�f/T2d� •�•�.,p�7jt�rrdu ivy' Address: 5r //,V)'7 41'07 city/starcizip:4hezI �I _ ZZ4! mono H: iL 7-Za-2-YffeJ Art an employer?Check the appropriate boa; 1.E 1 am employer with� 4. ❑ 1 am a genera! b. ❑ New construction contractor and 1 . of project(required): 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 11. U313emolition —P0V';1-/a1, wonting for me in any capacity. workers'comp. insurance. 9. Q Building addition [Ko workers'comp. insurance 5. ❑ We are a corporation and its lO.Q Electrical repairs or additions required.) officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or addition& myself.[No workers'comp. c. 152,§1(4).and we have no 12.0 Roof repairs insurance required.) t employees. [No workers' 13.❑ Other comp. insurance required.) •Any uPiihcaal Shia checks box el mats aho till out arc waim Lcluw clawing their works'cumpa mdioo policy inior iqx ' I Iwrwrtwnen who submit this oetidavii indicuina they are doing ail murk and thou hits outside eaotraaen met.uhnit a new arridxvit indicoting aSch. �Cumtwuws lhn chock the box man anaehd an athtithmal chart cawing the name or the st b-e ruswz and their wurkete'map.policy inlbrmatim. I am an employer that Is providing workers'compensad in insurance jot my employees. Below is the policy anti Job.site iujurutwwn. Insurance Company Name: rSif�l// 3P� .�rt��[/�/�^ Q ,.�� Policy 4 or Sclf--ins. Lie.0: -Al— p ..��5_ ZC2ZZe2.@1a Expiration Date: Joti Site .Address: In© i9;VV - ST y p: 5 a P Cit iStatuZt s�iJ i Attach a copy of the workers'compensation polley declaration page(showing the policy number and expiration date). Failure w secure coverage as required under Section 25A ur.IGL c. 152 can lead to the imposition of criminal penalties of a hnc up to S1,500.00 and/or one-year imprisonment,as well as civil penaltics in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this statement may be torwarded to the ODice of Ins•e,ngmimu of the DIA for insurance covcraye vcriftcation. /du hereby certify under t/te pains mud penu/ties ufperfury that Ilte inforinut/on provided above is true and corrccL tii!:rrturp• -t' �`>.") !�✓.yGl^ Date- 7 17-9 9N�21/11 OffIrial rase only, DO not write In thlr area,to be cuetpleted by city or town o/Jlrhd City or Town: Permit/IJcense M Issuing Aulburily (circle one): L hoard of llealth 2. Building Department 3. Cityirossn Clerk 4. Electrical inspector 5. Plumbing Inspector b.Other Cmmtact Person: Phone p: Information and Instructions blassachusems 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 contras of biro, express or implied,oral or written" An employer is defined as"an individual,pareaershtp,association.corporation or other legal entity,or any two or more Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership.aswciation or otter legal entity.employing employees. However the owner of a dwelling hates 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,cunwruction or repair be dock on to h dwelling house as employer." or on the grounds or building appurtenant thereto shall not because of such employment h1GL chapter 152,425C(6)also states that"every state or local licensing agency shalt withhold the isstsaaee or renewal of a license or permit to operate a business or to construct buildings is the commonwealth for say applicant wbo has not produced acceptable evidence of comPHance with the insurance coverage required." Additionally.MGL chapter 152,425C(7)states'Neither the commonwealth nor any of its political subdivisions shall enter into any contact fot the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contacting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary.supply sub eomractor(s)name(s);address(es)and photo numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or piutners,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 Departrtent of Industrial Accidents for confirmation of insurance coverage. Also be sure to situ mad date the affidavit. The affidavit should be returned 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 low or if you are required to obtain is workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the a Aerie line. City or Town Off ciab 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 applicaL 131euse be sure to fill in the permitflicetue number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense 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 inay be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or 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. 1'he 011icc of Investigations would like to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The Dcpanment's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Oates of Investiptlons 600 Washington Street Boston,MA 02111 Tel. Al 617-727-4900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 Revised i-26-05 www.mass.gov/dia PUBLIC PROPERTY DEPARTM&NT ic�..nts+r o�sonrL wwa t3D rP ��su+ur N�srrrs ot9�0 APM.ICATION FOR THit RTPAi>e_ 2AWYAMN CONMUCTION D 1.0 SITE INFORMATION Lo=*M NWW a rti lslra �` Le Add- ---------- --- ----- -- Properly is boated in a:Conssrvown Ana YM Hisforls Dis!!kt YM , 2.0 OWNERSHIP INFORMATION 11 Owner a/Land MooeplrG a r f-cr� i Nartw. Addreaa D �'X MA • oIq j Telsphane: 3.000MPLETE THIS SECTION FOR WORK IN EKUML"BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use 07, New Demolition r°'/a Tb err Existing Approximate yaw of I Area per now(at) Renovated construction or renovation 154DsQ New Of existing building Bast Oeseription of Proposed Work: /'Prrov� Afies7c$ -rAv,.✓ eawe �SO �y cow be ae"&-j aid FeHewd aAr Sire --- -- ---Mail Permit to