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274 LAFAYETTE ST - BUILDING INSPECTION w"1Ak *ETKap4 NWROVGD By TME JdsplecM MWX TDAP.EAW BEING GRANTED CITY OF_SALEM Dab r, in Y«L Nw_ w�sa mod)`/ 91^PT1`e-s% Is IAop.ny LoomW In Va GmurAdon AWO YsL.MV BU LDW PERMR APPNCATION POW Permit to: (Clrole wttiotwver apply) Rom Rowl, UgW gyp, Cwwlnwt D" Sled, Pool. PLEASE RLL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESS" TO THE INSPECTOR OF BUILDINGS: The urtdarsiprwd twreby applies for a pwmk to build aocw*q to ttw fdlowirp Ow Ws Nan* -off,-) Abp,) Anl Address& Phone G,4Ej� ST- L t Afd*eeda Name Address & Ptans j 1 Medwnics Name �)j LLi/4+�, 1 4v9cg cLu SbV s-y.3 - 9399 Address & Phorw S osQ � ��j (( vG ;)9 wllm Is w plrposs a ouraney as j )e.✓%t�L UANW Of oWairloy_W m(DA r a*me&*.for now many bwAm? Ye twiwq awdwm to law? A01"? EMwlmrad oat 5 a��a qly Uomw r N A 81w • (� of Applimt SWW UNDER THE PENALTY OF PUMORY DESCRIPTION OF WORK TO BE DONE GCocJa) -r— {3Jr� a c' rh rr✓�(s l e �i"iX r c�ia�9 �cJcV �roN MAIL PERMIT TO: 9 th- 0-1•✓0b, .S SOI�N f18 d b d cdAOkJddl/ xz,%7W2w G Z NMVDC '1 S�rvu.it� 1 J° Cla aL iffa d • ��*ON ti The Commonwealth of Massachusem Department of Indust►id Accidents offim of IRveseigadons. 600 WashingtoR Strad Boston,MA 02111 WWWRIM&SOV la Worken'Compensation Insurance Affidavit: Buflders/Contradors/Electridans/Plumbers A li n Informa o Please Print LSKM Name : Address:SSrcrJeLU� 2 city/statemp: A AgJJ uk!5 Lo �P/`� Are you as employerT Cheek the'aPProP�btu: Type ud Proied(required): 4. 0 I am a geaeral contractor and 1 6. 0 New constracnon 1.0 I am a employer with • have hired die sob oo�r�cio>s employees(full aa/or put torte} = 7. ❑ Remodeling 2. I uo a sole proprietor partner- listed on the attached sweet These silo-eonlrae0on have S. ❑ Demolition hip and bave no employees workers,COMP.bMUUM 9. ❑ Building addition working fir me in any capacity. 5. 0 We are a corpordtion add its 0 or additions (No.��'romp'iusWMW offiaas have exercised their 10. Electrical repairs 70Q*al right of exemption per MGL 11.0 Plumbing repairs or additions 3.0 I am a homeowner doing all work ker' comp• ." a 152,1 1(4),and we have no 12.0 Roof repairsmyself. [No wor ke employees. [No wodm' 13.91 OtherC�� 1/QY �9 /2 insurance requir ] comp.insurance regWN&I. �— 'Any ePP�t dW cheeb box Ni U"sloe 5D out me wedon below showioa Mee wokee' Sion Pommy Wwrnenos t Homrowom wko&*nut mi$of wkwd 06odh s fty are doing ill wok and men bun oufade wMsdm=M submit a new nBb%*iodic Js aueb. 1Coureem met chock thin box must a Wjwd m eddMoad abed abowng to none of me Wbeontndon and meir wo*M'OMVL Policy infoenwaim law art ewploya that is p►ovtdind worbn'cornpnsadon bu rents for my employees, Bdow is the policy ead job ske information, T,�,��f��rs ,✓S Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: n � rr �F>�y2fie' ST .�� CSty/StatelZip: �/�/ �© Job Site Address: Attach a copy of the worker' compensation policy declaration page(showing the Polley 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 Out-Yea imprisonmen6 as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to 5250.00 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 in WxoQC coverage verification. I do hereby eerie under the pins ardp drat the beforaados provided above b tits and correct #. v 6 9 F ldruedtrly. Donotwdm in this&"a,to be cow,plemd byeO ortawn oaleldor Town: PermWUceaIeng Authority(circle one): ard of Health 2.BuMng Department 3.C►tyrrown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Coated Penoa: Phone#: itLliwVl 111aa16iVll fila.K 1a1061 U%,a.lVnl►7 Massachusetts General Laws chapter 152 requires all employes to provide workers'compensation for there employes. Pursuant to this statute, an empWee is defined as"...every person in the service of another under any contract of hire, y express or implied,oral or writICL" An earployer is defined as"an individual,pwMas*association,corporation or other kcal entity,or any two or 1110110 of the foregoing engaged in a joint enterprise,and including the legal representative,of a deceased employer,or the receiver or trustee of an individual,partnership,association or other lMd entity,emptying empbye L However*a owner of a dwelling house having not more than three apartrmmta and who resides the em,or the occupant of the dweling house of another who employs petsons to do maintenance,construction or repair wort 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 152,125C(6)also state that"every state or local licensing agony doff wkhbdd the isssance or resewd of a neeea or permit to operate a business or to construct buildings In the conamoaweslth for say applicant who has net produced acceptable evidence of compliance with the hourasee coverage require&" Additionally,MGL chapter 15Z 125C(7)states"Neither the conmoonweahb nor any of its political subdivisions shaft enter into any contract for the performance of public work until acceptable evidence of coaplince with the insraanux requirements of the chapter have been presented to the cog authority." Applkaa/a Please 5fi out the wvorken'compensation affidavit completely,by checking the boxes that apply to yaw situation and,if necessary,supply sub-contractor(s)name(sl addresses)and phone number(s)along with their eetti9cate(s)of insurance. Limited Liability Companies 014 or Limited LiabrL'ty Partnerships(LI.P)with no employees other than the members or parinets,are not required to can workers'compensation insurance. If an LI.0 or LLP dos have . , employees,a policy is regrind Be advised that this affidavit maybe submitted to the Dgwuneat of Industrial Accidents for confirmation of fosu nmoc coverage. Also be sun 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 Accideuts._ 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 appropriate line. City or Town Offiefa4 Please be sure that the affidavit is complete plete 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 we to fill in the panMcewe number which will be used as a reference number. In addition,an applicant that must submit multiple permitticense 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 location in (cagy or town}"A copy ofhere affidavit dot has been officially stamped or marked by the city or town may be provided to the applicant as proof dot a valid affidavit b on file for&One pe nits or licenses. A new affidavit most be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to stay business or commercial venture (ice a dog Boman or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would Mice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a alL The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of I1svtilgations 600 Washington Street Boston,MA 02111 TeL #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26 os www.mass.gov/dia CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT o 120 WASHINGTON STREET, 3RD FLOOR 9�NIN8 SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Buildins Department Debris Disposal Di 1 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 111, S 150 A. The debris will be disposed of in: �- Gyr(es 1,Loca ion n of Facility) Signature of Applicant l( 12 z OS- Date i