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6 HALSEY WAY - BUILDING INSPECTION w #,4 eY wh y M P"WIN Lamad b X Lostta� d SA cL ar NbIbu o n, - * 'I Yo��Mo Y PUPEW Lol d M anOWAWW ORANO YoL.No_ MIMLDMID PIMW APPLICATION FOR: Permit ox (Ckae whiolrwr apply) Rode Read. kiMeN 8id/nY- r CarMruotnnDsok Slleti, Pool. RepaidlIOM K"U PILL.OUr LSO ■LV A COMPLEMY TO AVOID D"Vi M!PROCM SMla TO THE PdWECTOR OF WALMM The undwoonad hmW appWs for a pwrA Io build aooadinp to the IoNowirp woftsom Owners Naww /dt'1 z�O C A Addy ass A Phi ff LS�Y � r 7� 7 4� 6 s Arddbuft Name Address 6 Phone . r L Wwv;= Nel11e Address A Phone �rq� wart r<sw p"M a wmMr YZ P C t#wdd a trlall f 14C— / r a aNe ft ar now WAN wr wart aoadoao to kw? EoWatldas 7 0LVo coy • N A MYa a `�00o am pXSVOwo U � PENALTY OPPELRM DRURMON OF WOFX TO U DONE �(7rcG� �w 8e-faH Fxr7'e".rim.7 No. o� APPuCmoN FOR PTO LOCAT POW GRANTED l 6 NOPECTOR ofMON-GIS CITY OF SALEMO MASSACHUSETTS 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 Disposal 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 I11, S 150 A. The debris will be disposed of in: (Location of Facili Signature of Applicant Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgovMa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 'a- t Please Print Leeibly Name (susness(Orgmization(Individual): ` Y-f r-s,4b C. Address: C5-0 G t sS 5 TT City/State/Zip: l (f1_ C D F h Phone#: ) / 92- `7 Are you an employer?'Check the appropriate boa ' "`l' ' `' Type of project(required): 1.❑ I am a to er with I f 4.''❑"I am`a general contractor and I 6 amp y ❑ New construction ` employees(full and/or part-time).' have hued the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet t ?• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any,capacity,. workers' comp. insurance. 9. ❑ Building addition [No workers' comp:insurance 5. ElWe are a corporation and its` 10.❑ Electrical repairs or,additions required.]'i . it ,,­, I officers have exercised their' ` 3.❑ I am a homeowner doing all work right of exemption per MG& 11.❑ Plumbing repairs or additions myself. [No workers', comp. C. 152,§1(4),and we have no 12.❑ Ro'frepaus 'I le - ` 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'contpensation policy infommtioa t Homeowners who submit this affidavit indicating they are doing.all work and then Lire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the suDcanlnictms and their workers'comp.policy information. I am ari employer that is providing workers'`compensation insurance for myemployees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: t Job Site Address: City/State/Zip: 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 under the pains and penalties ojCpedury that the information provided above is true and correct Si_ifmattue• `// // Date: Phone#: QffIcial 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#: Information and Instructions Massachusetts 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 contract of hire, IQ express or implied,oral or written." c •.rya �. An employer is defined as"an individual,partnership, 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,association or other legal entity,employing employees. However the owner of a dwelling house having not more than-throe apartments and who resides therein,or the Occupantof the - dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(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 in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall 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 boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited.Liability Companies(LLC)or Limited Liability Partnerships(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 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 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 their n appropriate line. _ umber o the self-insurance license n app P City or Town Officials 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 or citizen is obtaining a license or permit not related,to any business or commercial venture (i.e. a dog license or permit to bum 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 us a call The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office 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/din -- -- 67, License; CONSTRUCTION SUPERVISOR, t'f NumbeR S 090008 ! y . BIB t0E'k0/1961, ' tom„""—rk j �xpfiesrtD/_t8 Tr.no 9000E " MIRSAD HOST 550 CROSS ST MALDEN, MA 021 Commissioner ' ;