471 HIGHLAND AVE - BUILDING INSPECTION (2) • r
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ArcAi $Name � ( ) -
AddrMs and Ptah
modw+w'a Name
Ca 3�irs Lkar,aa ` 5 HIC RegWaWn 01
Estlrnaad Coat a Projaot s -500 D Pam*Fee Calare
-o o Esdmabd Coat X i7/i1000 ResWWW
Permit Fee i
--- - - - Esdmatad C04 X i41/i1000 COfflnw va An Addblond i0.0o is added as an
AdminkW"aMrga.
Make sure dud aN fldds are properb and loobly written to avoid delays to p mening.
The undardpned do"Eby a"for a Buildit Pam*to buUd to to above stated
spaeMieatbna, signed under panaft of Perjury
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a PUBLIC PROPERTY
DEPARTMENT
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"PLCATION FOR TRZ RU M >Q1QxnV� rrnnr ��,�r�•.•e...•T.....
DIMAKH iTIM OR OAM of USt OR OCCIJP NCY FOR •NY >p.rranNG
S'Il'RUCPURS OR B�>�1a11tB
1.0 SITE INFORMATION �,,.1�e--Location No g�y�
RvwV Is boded In d;Cwwwvalbn Am Hbbtb DbMbt
2.0 OWNERSHIP INFORMATION
9.1 Owner of Land
Name:
Address.
Telephone:
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LETE THIS SECTION FOR WORK IN EXALTING BUILDINGS ONLY
Existing Number of Stories Renovated
Change in Use New
Demolition Exis
�
Approximate year of Area per now(st) Renovated
constructlon or renovation
of existing building New
Brief Description of ProposedWork:
o 4- Nc�J
--- —- ---Mail Permit to:
/tQ lJ6l)U)FMlfI/Q!l�tll C�'.�f✓,ms:acluae!!a .
- Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 153299
Expiration: 11/14/2008 Tr# 253345
:Type: Pate Corporation
PRIDE CONSTRUCTION_AND'DEVELOPMENT INC
CHRISTOPHER YOCUM
75 CANAL.STREET
SALEM,MA 01970 Administrator
CERTIFICATE OF LIABILITY INSURANCE
09 07 2007
(781) 595-2071 1
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f CITY OF SALEM
PUBLIC PROPRERTY
DEPART.%MM
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Construction Debris Dbpossf Affidavit
(required ibr all denotidom and genovatim wort)
is aot:onlattee with du duds ed den of dw stun Building code.790 t,11t section It t.!
Debris6 sad dw provisions of 1dQ.a 406 9 sal
OttiidinB Permit 0 _ is issued with the mWidos shot din debsie mmadng!tots
this wet shall be disposed of in a property licensed waste disposal facility as defined by 1d(8.e
ltl.5Is"
The debris will be transported by:
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(Mule of hmdd"
rho dcbris will be disposed of in : r
1 a 4n^c,h�<� st �-I
/(It mr of fxdlty)
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wt\far nl F.Y URLX:ULL
MAYaa i2C W^skn.Ns:Tmsfrtear a SAtrst,mAnAc9azst resoi97s
TbL-97i)45.9595 a FAX:9M?40.9846
Workers, Compensation Insurance Af9ldavit: Builder/Contractors/Electrktans/PMmbe»
Analicaut Information q 1 I Please Print Legibly
Name tHuainnss/OrYaniratiavlm4v�Jtnn:�i e/
Address: (—' gvtc, 1 s
City/suceizip:5a f,-M-- Ac, U14 �O Phone J1:� 8 "zi�2 ! 488
,tro,va. 6 an ompley eat t or?Ch e appropriate bons Type of project(required):
1.0 I am o empksyar with 10 4. ❑ 1 am a general contractor and 1 6. ❑ NPW construction
employees(rull and/or purl-tine).• havC hired the sub-comractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• CTRemodclinS
ship and have no otnpksyoals Theas sub-Contmeters have g. ❑Demolition
working for me in any capacity. workers' comp. insurance.
rKo workers'comp. insurance S. ❑ We are a corporation and its 9. ❑ Budding ukfition
rcquirctLJ officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
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. insurancx rcqurod.J
Ally+PPtK�tM e1Rvits boa el mum also t""nt use the=91"twbw shallots rtMir errrkm'cumPmrvniw puicy ioGxa mica
Iluasowlmn who submit this amdavit indiwtins May am&*a all work sad case him easide gownetpa pout submit a omo attldsvi indices such.
(',lMrxtrea the$chuck dw boa mot anachd m adchlim l isms drwi g as,near tiro asobconamsmaand their workesa'come.policy inrmmasim
l oar an employer that Is providing workers'compenrraden Grsaratace jar ny employees Below is the poBcy end Job sUe
informatiwt
Imurance Company Name:C.,, »e
Policy 4 or Sclr-ins. Lie.#:.j3640 Expiration Date•./! -G'i-car
Job Site .A"ess: 1I-1( /4}t,(u ✓C CityiJWtu2ip:_5�:!(,- fit, cs(42o
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 ofa
rim: up to S 1.500.00 and/or one-year itnprimrnmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
or up to S250.00 a day against the violawt. lie advised that a copy of this statement may be furwardcd to the Office of
Inv.•ahyaumu ui'thc DIA for wiltrarce coverage verification.
l do hereby certify ender the pains end penellkir a/perfary thW the its/ormWloa provided above is tree and correca
%X—A� Dare /�i-f
Phiuic,y 5L(2 / -r&e
Oflkialuseluv/pt /err nor wrier/n tA/s area,to br camp/eled bil city or town offlejaL
City or 'ro%vn: --, Permit/IJcenseY
Issuing Authority (circle aim):I. hoard of Ileaith 1. Building Dcpartmcnl I. Cityffoen Clerk a. Electrical Inspector S. Plumbing Inspector
6. Other
Gonad Person: _ Phone p:
Information and Instructions
'vlaisachuselts General Laws chapter t52 requires all employers
to provide ervice c another under any* compensation for ttheirCt ofOYCM
pursuant to this statute,an awpfoyaa is defined as"...every person
hice-
eapress or implied.Drat or written"
lion or other legal entity.or any two or more
An asa jdayer is defined as"an,is�viduaL partnership.amoc>�eOR°ra or the
of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.
association or other legal entity.employing employees. However the
receiver or trustee of as individual,paraaershnP. euts and who residue therein.or the occupw of the
owner of a dwelling house having not more than three maintapartienance.
dwelling house of another who employs Persons to do maintenance,cusstruction or repair work on web dwelling house
or on the grounds or building appurtenant
ehemm shall not because of such employment be deemed to be an employer.'
MGL chapter 152.j2SQ6)also afates that"every state or local Beeasiat ageaey a"withhold the iastaaaoa er
too rate a business or to coustruct buildings is the commoaweakh far say
renewal of•Incense or permk operate with the insurance coverage requlred.-
applleaaa who has net produced acceptable evktesrb of a commonwealth
ors of its Political subdivisions stall
Additionolly.MGL chapter 152,$2 s 'K'leidner the conutartwealth nor arty
enter into any contract forte performance public work until acceptable evidence ofcompliarca with the insurance
requirements of this chapter have been presented to the contracting authority."
Applkaats
Please fill out the workers' compensation affidavit completely,by checking the bones that apply to your situation and,if
necessary.supply saiwAntracwr(s)narne(s),address(es)and phone number(s)along with their certifica a)a er than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LI-P)with no employ
00111 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 license and datebeing the Affidavit. The rested.not the De tp�davit should
be returned to the city or town that the application for the permit low or i is You ers required to obtain a workers'
t Of
Industrial Accideats. Should you have any questions regarding Y
compensation policy,Please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the atioroortairr line.
City or Tows Offfclob
Please be sure that the affidavit is complete and printed legibly. The Deparatent 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 applicsns
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple Pe applications in any given year,need only submit one affidavit indicating current
lte Address"the applicant should write"ill locations in (city or
policy information cif necessary)and under"Job S
town)."A copy of the affidavit"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 now affidavit must be tilled 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
IN; Oftwc of Investigations would like to thank you in advance for your cooperation and should you have any questions
plcuse do nut hesitate to give us a call.
The Department's address,telephone and fax number.
The Cointnonweslth of Massachusetts
Depatttaent of Industrial Accidents
O11tea of loved1godens
600 WashinSton Sftd
Boston, MA 02111
Tei. p 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
2eviwd 5-26-05 www.num.gov/dia