412 LAFAYETTE ST - BUILDING INSPECTION -K:MSIAVST9EflliAi JD APPROVED BY 744E
JW,ECMB,P431GR TDA.PEBF AFJNG GRANTED
CITY OF_SALEM
No. \ D.W /4 z6 - aS
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Skhny, Construct Deck, Shed, Pool,
Repm/Replace, Other. K/c HF,,✓ r?Em o ZZ-41IV4'
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name 57,W4F f JoA,✓ I/N I/O ca 1) FS
Address & Phone 412 Za-F.9.4E 7%-E 57-. (276 7 4S- 5 3 /8
Architect's Name IV14
Address & Phone j 1
Mechanics Name RAn/CIA// X , om,07-OAl
Address & Phone y/ Lake- Abe- 4,c LM11 S8/- 33 84
AyN Af- 0/57o4
what is dw purpm a bundkp? ,2- Agm,14
M"W of twlldirp? Cc)o 0 4/ B a dm&V,for how many f.w in? 2
Will bu k irq oontorm to law? 4e 5 Atbsstos? ND
Eamoml coat -8, o oo. Cw uosnw# N " st t.ucwm 0 D 4 90 9
U`. 74 Signature of Appl cant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO. ?el2om?—t dA/ V ZVAef �Ew �a6 �/✓/✓ /�A
• 0/904
No. �
APPLICATION FOR
PERYR TO
LOCATION
Ll1
PERMIT GRANTED
20
s
AP ONFD
INSPECTOWOF BUILDINGS
CITY OF SALEM, 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:
.Cy.✓.✓ (Location of Facility) C.rrn� �2Ci p 5 T
Signature of Applicant
Date
1/,9 v G
:f
s
.� a � •ra .a1ai� A..♦ a2 �M1 F"
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s
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Is 600 Washington Street
Boston,MA 02111
www.massgov/tdia
Workers' Compensation Insurance Affidavit: B»tflders/Contractors/EleP id pal umbers
ease Lezibly
Alpiplicant Information /•n/37
Name (susmes�Or>tint, ividuat): nZo/►1Pi 0of CARD6NT�y a ` 1nIC
Address: j A E Vl E w 14,e
Zi
��
Ass o/4oa Phone#: /- 7A'/• �5'B/- 3 3� 4
rate/
Ctty/S p:T—
Are you a■employer?check the appropriate box: r7R:
f profs(rep ed):
I. I am a employer with_ I___ 4. 1 am a genaal contracror and I New construction
employees(full and/or part-time).* have liked the sub-mntractim ing
etor or partner- listed on the attached sheet t
2.❑ I am a sole propri These sub-contractors have Don
ship and have no employees workers' comp. insurance. B addition
working for me in any capacity.
[No workers' comp. insurance 5• ❑ of area corporation d t its 10.E] Electrical repairs or additions
officers have exercised rhea
requmd] right of exemption per MGL 11.[] Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work c, 152,§1(4),and we have too 12.❑ Roof repairs
myself [No workers camp. employees. [No workers'
insurance required.]t 13.❑ Other
comp.insurance required.]
•r�Y aPPl t tbet chectm box#1 must also fill out the section below sbowing dram wvrken'compensation Policy=&MIstion:
t HomreoWaco wow sohnit this affidavit indicating they are doing all work and then but outside contrecton must submit a new affidavit indicatmfoing such
tconuactors that cbmk this box must eftwhed an additional sliest sbowing the name of the sub-cwtraGors and diek worked comp.Policy
I am an employer that is providing workers'compensation Insurance for my employees Below is the poiiry and Job site
information
Insurance Company Name: %tk IQ 11C1 E'R S SN S U,1Aa 4NCF
Policy#or Self-ins.Lia#: �o K U ' 7 7 3 K gs�7 Expiration Date:
Job Site Address: 4/ _City/State24:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date}
Failure to scare 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 in>prisooment 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 cenft under the pains and penabiss of pedury that W Information provided above is fte and eorreeiG
Date
/D - Z!o . 0.5-
Phou
CM
Offlclal use ims)K Do not writs in this area,to be eompkied by city or town offlelai
Chy or Town: PermfNLiause#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Coatad Person: Phone#
1111V1 all ai l.iV11 "AA%A 11104111 al\r a.1Vl1A7
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 writtes."
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 apartinents and who resides therein,or the occupant of the
dwelling house o£amther who employs persons to do maintenance,construction or repair work on such dwelling hose
.,.:„
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 licensingagencyshall 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 evidesee of compliance wiWthe 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."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)namc(s),address(es)and phone number(s)along with their certificatc(s)of
insurance. Limited Liability Companies.(LLCM 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 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 call the Deparmunt at the number listed below. Self-insured companies should enter their
self-insurance license number 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 regattlmg the applicant
Please be sure to fill in the perriMcense number which will be used•as a refercricemugber.,In addition, an applicant
that smut submit multiple pernuOicense 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 kuatlons'm . (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 nun be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.c a dog license or permit to burn leaves etc.)said person is NOT required tb complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
lease do not hesitate to give us a call.
The Department's address,telepbone,and fax number:
The Commonwealth of Massachusetts
Department of Indushial Accidents
Office of Investigations
600 Washington Sheet
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26 OS wwwmm.gov/dia
7
Qom•-��n torn i irlVA i r- cat LIABILITY INSURANCE
PRODUCER THIN CM*VATE IS ISSUED AS A MATTER OF INFORMATION
:. ONLV AND COWERS NO RIGHTS UPON THE CERTIFICATE
William J Lym*1mummee Agmey E WVERAGECERMCAA�OEES NOT A�UCIES RELO R
44 Maple Stmt,Sake 3 ALTER E"- ,MA 01923
- vsrsUflERS- AFFORDING COVERAGE
MNMLT!
6ompton Calpmtry&Cont.,Inc q rce company
' 91 Lake View Ave INelneLa >mmurnawR ompxny
Lycra.MA 019M GaLmEn a
i AYSLNEnIX
R61RiFAE `•-
i COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INS UREp NAMED ABOVE FOR TH2 POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REUTAREMENT,TERM OR CONDRpN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WEIGH TR19 CFATIWCAIE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIGED HEREIN IS SUBJECT TO ALL THE WHICH
RMS. THIS CIONS AND ECONDITIONSMAYI OF SUCH
POLCIES-AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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RE: All Carpentry&Construction Operations of the above for The City of Salem
CER7TU ICATE HOLDER Anon oRm.adman AA MaR Uwrn E CANCELLATION
A1ION
SNW W MIYOFTAEADOTE DE949®�FDUGES GECANCENBP 6EFORETHE tYPOMTIOM
-City of Salem UAW TAEAEK.ME*Do*asuam TILL awavo R YO A" _DAYS MRRTEN
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Salem MA 01970 OR-UMMW Y AP AIR IIR,R UPON, R 8 qEA.me. TM
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