Loading...
325 JEFFERSON AVE - BUILDING INSPECTION (2) Dft z� Is Rmpft L=60d in blr�roMo011Yk11 Y��No� r pmWM 1ooNad In AU.,� rrOarNll�rO�IMd Y�,1M� B{N1,D"PlIMMf ApPL"TIDN FM Permit UK Dftoir. ShNl. (CYor wtridNwr appy) � ,�'e, e-C 6c� el-�e tl PLEABE PJLL OYT LEtiMV A COYPWMY TO AWM Dp. U N PROCEN" TO THE INSPECTOR OF BUILDIP M MW WrdaSipr" hK* Sppw la s Pom* 10 bM ri000rft tD " toYW" wooftodwm Ow of*NWM /�'�A /�(� �✓,r�a�G�L A m& Phone Arotrilect's Name Address A Phone _ I Medr MM Name Address a Phone ftd ra rr prpw al s~ a w�- L(ahrr� raM,r,r d e~ red••wa ror how rrwrr*awiwz wrr bait Goom a W? y -eS A.d.nor, 6mod oat Yo 000 CMS/LkMIM 1 NIP. MYft ul/ 0 CS 0-7(o Z q(p impnvmmt e8 v6D us �I 3L o x of som UNDER THE PENALTY OF PMLRM DESCRIPTION OF WOFX TO EE DONE C�etm© deL &=C- ell ,,- oOLJ / / ZAj A+t fi4 �- 0-4,f a,'4-C-f, -vp ��i12 �/ PI ov No. APPLICATION FOR PERMIT TO FYAH'�01/i Jo, C GLO�.A T10N PERIAT®RANTED to prSP of OLALDIM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians./Plumbers Applicant Information Please Print Legibly Name (Bnsinescs/organizat(A/ion/,,I,naivianal): 'Q Address: o� Y` City/State/Zip: Phone#: 7 ° Sb 2 Are y an employer?Check the appropriate boa:', '' Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. El constriction employees(full and/or p time).' have hired the sub-contractors ,�,/ 2.El am a sole proprietor or partner- listed on the attached sheet t ?• U 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 10.0 Electrical repairs or additions required.] : .,s; officers have exercised their' 3.❑ I am a homeowner doing all work right of exemption per MGI 11.E] Plumbing repairs or additions myself. [No workers .comp. c. 152 §1(4);and we have no 12.❑ Roof repairs - , insurance required.]t. employees. [No workers'; 13.0 Other comp.insurance,required.] " *Any applicant that checks box#1 must also fill out the section below showing theirrworkets'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractots that check this box must attached an additional"sheet showing the name bf the sub-contractor;and then workers'comp.policy information. I am an employer that Is providing workers'compensation insurance formyemplayees. Below is the policy and job site information. J S.T, ��(�L ©© (( C Insurance Company Name: �/�GJ Policy#or Self-ins.Lic. #: ? 7 Tl1O J�U D(30,5 '- Expiration Date: Job Site Address: J Z J-�O`J A — City/State/Zip: 01170 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 cruninal 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 an of perjury t at the information provided abov is true an correct !! Si Z /Signature: -Z Date: E Phone#: O Z 01 3 Official 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 Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions M 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, 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 apartments and who resides therein,or the occupant ofthe<='< - 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." 4, a Applicants r. - 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 of 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"'ompanies should enter their self-insurance license inimber 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"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 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-NIASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia 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 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: (Location of Facility)—A-) / 4nalture of Applicant Date l20' r 12" 30" 56" 24" 45' 24" 51 r . N WA' W303660 W02436R �BF3-3�18.DISHW _—•_ _.. b._ a + Oe ^ O v Q m m m w o o m CD m � i N O d 090 : ) RW3618B6) ' 1 i '11;'1"I- "t 1 0is' toil All dimensions size designations given are This is an original design and must not be Designed: 1/10/2006 subject to verification on job site and released or copied unless applicable fee has Printed: 1/10/2006 adjustment to fit job conditions. been paid or job order placed, MOM LUME M � ro marls trPmhlaar rh and/rr rivn achx-trillI All I