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263 JEFFERSON AVE - BUILDING INSPECTION 14ANS WSt-9E f ND APPROVED BY T44E kWXCZW PBIGR TOA.PEl3tf1T ACINO GRANTED CITY OF SALEM No. caw Is• mpwV L0001Yd in Location of rw waoato olddct? Ye. No✓ "{� G 3 ,� .-„ala Is Properly LooWmd In do Cormmagn Area? Yerr No f✓ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, I Wl Sidln Construct Deck, Shed, Pool, Rwwrfi eplace, er: 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 Namee— Address & Phone Architect's Name Address & Phone �j ✓ j ) Mechanics Name �- Address & Phone Whk Is the p xpm of bulklkq?---a�� Mal m of buklkv? _ Ct sic °� r vro-� n a wreYUq,for how moray twin? I wa bowd4q owdonn a Iaw? n@b ? :Z� EsYnrated cost Y©a o, o C' Clly uowrw rr N C► WAW Boa Lpsoveraaat X 9•wLi c. / /oo/G7 SiprWure oll Applicant SKANED UNDER THE PENALTY OF POWURY DESCRIPTION OF WORK TO BE DONE r— MAIL PERMIT TO: , No. APPLICATION FOR PERMIT TO LOCATION PERMIT-GRANTED ZO� 20 CP � INSPECTOR OF BUILDINGS 1 b_ The Commonwealth of Massachusetts Department of Industrial Accidents Offiee of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letaibly Name (Bosmascrpm=u°nRnd'viaoal)• " a, t— s Address: 1 '"< .,. 22- C Phone#• City/StatelZip: A,re.y a an employer?Check the appropriate boll: r7C3 �Prof7addidou I.Lh I am a employer with 4. ❑ I am a general contractor and 1 New con employees(full and/or part-time).► have hired the sub-contractors Remodellisted on the attached sheet t2.❑ I am a sole propnetor or partner- These sub contractors have Demship and have no employees worktas' comp.insurance Building working for me in any capacity. [No workers' comp. 5. ❑ We are a corporation and its airs or additions required.] insurance officers have exercised their 10.❑ phmlbcal rep 3.❑ I am a homeowner doing all work right of exemption per MGL 11•❑ Plumbing repairs or additions a 152,§1(4),and we have no12.❑ Roof repairs myself. [No workers' comp• insurance required•]t employees. [No workers' 13.❑ Other comp.insurance required.]. 'Any appliemt dint checks lox#t mat also fill fill out the section below showing tlmert wodtm'compe'p81fim Policy infommadod ?Homeowner who subnut this affutevit indwsheg they are dig all work and than but outside conhactots must submit s new affidavit iadice"such tConnncsors dot cbeck this hox must attached en aM ion l sheet showing the name of drc suboontmon"end dotr wotkm'comp.Policy information. I am on employer that Is providing workers'compensation Imurance for my employees. Below Is the poliky and Job sits hafe"n aloe. G Insurance Company Name: Policy#or Self-ins.Lia #: iv C 0 0 7(o Lid 27 �o � Expiration Date: � Job Site Address: ��3 City/Statel'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 insurnce coverage verification. I do hereby een*under the pales and penahks of perjury that the injormadon provided above is trio and correct 5 n Date:Phone !oI3 / IGs #: 2— O,Q'kial use onlyk Do not write in this area,to be completed by eky o►Imm official, City or Town: PerinlYucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cttyllown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone# Contact Person: l llil Vi iilNbiVii Nile lai►7 a.1 M\.11Vil.►7 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their einpioyces, pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of Lire, 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 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 three apartment;and who resides therein,or the occopant of 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 152,425C(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 in the commonwealth for any 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 Shan enter into any contract for the performance ofpublie work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fin out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(I LP)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 resumed 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 can the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate Use City or Town OlHcish 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 fin out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fin in die 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. A new affidavit oust 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 (ie. 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 besitate to give us a can. 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 5-260s wwwxaass.gov/dia 0 CITY OF SALEM9 MASSACHUSETTS s A 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 Building 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: ..),-6e-,-\ (Location of Facility) Signature of Applicant Date