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45 LAFAYETTE ST - BUILDING INSPECTION -Pla 1 *IW*E fiIA94N0 40MVGD f3Y TW JdSP TGB PWR MD A PER4W AOM GPIANTED CITY OF_SALEM _ L �. -off s tin NMpb OY4iCt?In Ym _No-L !%l"as �/Jr�i�llAYc E sT bPmoty Lacmdin the OoaNnaaon AM? Y«,_No BULDBfi<i PERMR APPLICATION POW Perk to: (Ckole whiohewr m*) Roof. Reroof, Instal Sidlrtp, Carntruot Deck Shed, Pool. Repau/Rsplaoe, Other: 7"ourt�Tii/�2oJ�� PLEASE Rol OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDING&' The ttrtderagrad hereby applies for a pormt to build aww ttp to 00 toW*vV j Oawoes Name /-[.o -Ross 7�20e- 64 Address a Phww /7 -ZV41oo ST Spvfp2✓i/f- L( 7 I 83/L Arcfineas Name NIA Address i Phone Mechanics Name Address A Phone L wiec a w pWvo••a burarp? /�o��S r`�R�" mom a blridYlp? C'a.�',2�� N a otwarir g for how sang lomm"? vm b Awv and m to law? V MbNlos? �O Earm�tad coot 5�©©D qqr uorw• N A stwr b _ UNDER THE PENALTY OFPELRMY DESCRIPTION OF WORK TO BE DONE �/ Sc�/� �r Gv�RK /S, Us AR��ZA4 Qf-2PE:7—Z1,vc, MAIL PERMIT TO CITY OF SALEMO MASSACHUSETTS * 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: (Location of Facility) 4iiature of Applicant A Cl-,S- Date The Commonwealth ofMassaeeusens Department of Indusoid Auldents 0,84cs ojlmestigadotu 600 Washington Street Boston,MA 02111 wtvrdimass go-WAW Workers' Compensation Insurance Affidavit Bugders/Contractors/ElecMciana/Plnmbers Please Print Legibly Appocant Informs 10 Name Address: City/Statemp: Phone# Are Yoe a■employer?Cbeek the appropriate box: Type of proied(required): 1.❑ I am a employer wits 4. ❑ I am a general contractor a�I 6, New oonstractioa employees(W and/or part dme).! have hired the attachub-coed shectors 7. ❑ Remodeliag listed tm the attached sleet t 2.❑ 1 am a sole proprietor or partner' These sub-contractors have 8. ❑ Demolition ship and have to emploYeea workew comp, iosmance. 9. ❑ Building addition wonting for me in any caPwitY• S. ❑ We are a corporation and its [N?I�a!l COS tnsurance officers have exorcised their 10.(] Electrical npa6s or additions regnifed•] right of exemption per MGL I I.❑ Plumbing repairer or additions 3.❑ I am a homeowner doing all work c: 152,)1(4�and webaveno 12.❑ Roof Mail myself [No wolteii- enn>Qemployees. [No 13.❑ insurance requited.]t comp.insurance required.]. Other •par eownmr ttrr them Iwx a rant % cg oW dwy the xe ion4o�wwatt and b bim 0013de,' 000tiactorw mud mbn*&row ioevo io n such t Ho VWWrX Is who w k the this affidavit iodic an a d5fi dome &a owns of the nub mmucton and*ek workW eonq.Potiq Mfornee"00- rContracbta thwt cheek this two rout etterbed an eddrtiowd sheet whow'vq - .. I am ere ewpfoyw flat is provldlnd workers'coatpeasadae brsurancefor my employees. Blow h the Polley aed fob site baforma twL Insurance Company Name: Expiation Date: Policy#or Self-ins.Lic.# Job Site Address: Chy/Stateft: declaradoa page(showing the poky number and expiration date). Attack a copy of the worksn eompenaattloa policy of a ead to the ition Of fi Fallon tosecum coverage as required under Section 25A of MGL o. 152 can l off a BTOP wORDER and Penalties ORK a fine e up w$1,500.00 and/or one-year imprisomnew,as well as cia penalties the of up to$250.00 a day against the violator. Be advised that a coda'of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the Pak"and penakles ofperfary that the lnfinmadoa provided abow is ow sod correeg O,dfclal use orrlp Do ad wefts/w Als area,to br eoarp/Md by cky Or to"OJielat City or Town: PermMBleense# Issuing Authority(clrele one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6 Other Contact Person: Phone#: 11AA%F aaasabaVaa "ALM." taaaa.a %&%,%.aVu►7 Massachusew General Laws chapter 152 requites all employers to provide workers' compensation for their employees. Pursuant to this statnte, an employee is defined as"...every person in the service of anotlur under any contract of hire, express or mphed,oral or written." An muploya is defined as"an individual,partnership,association6 corporation dr other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including site legal representatives of a deceased employer,or the receiver or trustee of as individual,Partnership,association or other legal entity,employing employee. However the owner of a dwelling house baving not men than throe apartincists and who resides them,or the occapaut of the dwelling house of another who employs persons to do maintenance,construction or repair work on sacl dwelling house or on the gmunds or bwlding appurtenant thereto shall not because of such employment be deemed to be an employee" MGL chapter 152,¢25C(6)also states that"every state or local licensing ageney slag wkhbdd the hs"ace or renewal of a Heeese or permit to operate a business ar to cogstruct buildings in the commonwealth for may apptlenat who bus not produced acceptable evidence of eorp,Unce with the Insurance coverage required." Additionally,MGL chapter 15Z 125C(7)state"Neither the commonwealth nor any of its polities sabdh*iona sua11 enter into army contract for the performance ofpubHe wort until acceptable evidence of compliance with the insurance regttiremeaa of this chapter have been presented to the contracting authority:" Appllemab Please fill out the workers'compensation affidavit completely,by checking The boxes that apply to your situation and,if necessary, supply sub-contractor(s)named address(es)'and phone number(s)along with their catificate(s)of insurance. Limited Liabtlity Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other tutu the members or partners, are not required to cam workers' compensation insurance. If an LLC or LLP doe 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 sun to sign and date the amdavlt. The affidavit should be returned to the city or town that the application for Ake permit or license is being requested, not the Departatent 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-insared compama should enter their self-insurance liccuse number on Ake appropriate lime. City or Town Oflidals Please be sure that the affidavit is oomplete and printed legibly. 'Me Department has.provided a space at the bottom of the affidavit for you to fill out in the went the Office of investigations has to contact you regarding the applicant Please be sure to fails in the Permitlticeme number which will be used as a reference number. in addition,an applicant . that must submit multiple permiNicense applications in any given year,need only submit one affidavit indicating current policy information(cif necessary)and under"Job Site Address"the applicant should write"all locations in (city,or town}"A copy of the affidavit tint has been officially stamped or,maked by the,city or bwn may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenser. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a ficezin 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 The Office of Investigations would lice to thank you in advance for your cooperation and should you have say questions, please do not hesitate to give as r calL The Depatnkoars 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 OS www.mass.gov/dia