14 HAWTHORNE BLVD - BUILDING INSPECTION (002) L
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114L44NS1AWST9EftLE� APPROVED BY T44E
m PFGSLIB PBILIR TDA.PEB F AEINO GRANTED
CITY OF_SALEM
No. Date
Is Properly Located in Location
do Hsloric Oishfd? Yes No_ su+_;+A 'T
Is Property Loaaled In
I*CarwrvaYgn Ana? Yet_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof natelll Sld4tpp, Construct Dec/k, Shed, Pool,
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name
Address & Phone 16
Architect's Name
Address & Phone f )
Mechanics Name A66tiA�- �atis CoC
Address & Phone loa tC�wcJee->>=7- R D (?>l-)
Whet Is the popow d WNW 1c—xi/UL 1
Mdww of bulldog? n a dwWo.for row merry Iamilim? Ib_
WO bAdirp moan to law? Asbestos?
Erimsted cost 00 CYy uowm r N A Stall Licertw it
Ime t X
Sotature of Applicant
SXR= UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
3 %y%41- —
O 60 / ®C. C/(/'✓L�ll� .ylo-�ubiPi/ i
MAIL PERMIT TO:
S
APPLICATION FOR
PERM TO
tiybe.-
AQA r/or�
LOCATION
PERMIT GRANTED M
-670 2.0
APPAQ�D
INSPECTOR OF . ILDINGS
t
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
If Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant Information Please Print Lezibly
Name (Businesslorganization/Individual): J&i✓ti 61,52 17 t�
Address:
City/State/Zip: z., Phone#: C, 7,F-
Are you an employer?Check the appropriate box: Type of project(required):
1.E34`ain 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.El am a sole proprietor or partner-
listed on the attached sheet. t 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 I LEI Phtmbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.[� R'f repairs
insurance required.]t employees. [No workers' 13.❑ Other + ,e,
comp. insurance required.]
•Any applicant that checks box#1 must silo fill out the section below showing their worker'compensation policy infomation'
t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such.
tContractor that check this box must attached an additional sheet showing the name of the subcontractor and their worker'comp.policy information.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the polity and fob site
information.
Insurance Company Name: 716- T.@ a ye-/e v, s'.risv Pc> C o
Policy#or Self-ins.Lic. #:_e2d- %&)! /7 V—to/—d.� Expiration Date: L�
Job Site Address: /hr /�v��i�.t°.c� AdI� City/State/Lip:
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 Beni under the and penablet of perjury that the information provided above is true and correct
S' store: Date:
Phone#:
Odkial use only. Do not write in Als area,to be completed by city or town oJjFciaL
City or Town: PerntIVUeense#
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#
lnjormaLIUR auto i113ii UI L]LUl113
Massachusetts General Laws chapter 152 requires all employers in 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, a
express or implied,oral or written."
An employer is defined as"an individual,partnership, association,corporation tir 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
e having not more than three apartments and who resides therein,or the occupant of the
hoes 8
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
f r an
buildings in the commonwealth o y
nit too crate a business or to constructgs
renewal of a license or per p
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C( )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 numbers)along with their certificate(s)of
or Limited Liability Partnerships LP)with no employees other than the
.Limited Liability Companies(I-LC) r7rtY luP �-
insurance. Lmu tY
members or partners, are not required tn carry workers' compensation insurance. If an I.LC 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
self-insurance license number on the appropriate line.
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 Fall 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. 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 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 wwy,mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
a Q.
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildine 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 III, S 150 A.
The debris will be disposed of in:
�ck- ,e 1. (Location of Facility /1�oiz6 r' D �Sa/6i2<I
P �s y
nature of Applicant
/O//
Date