357 1-2 LAFAYETTE - BUILDING INSPECTION J .
.pLW4S.MIf1St9E flt.-W tND APPROVED BY T+IE
Mrp =PRIOR TD.A.PEW=NO GRANTED
CITY OF_SALEM
No. �� y�. Date Q> ' Z 'C-S
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Is Prop"located in Location of���/
tfw Historic DlsUict? Yes NO
Is Property Located in
no ConserAWgn Ama? Yes No
BUILDING PERMIT APPUCATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidin . Construct Deck, Shed, Pool.
RepaidReplace. Other: fi�'I�D B A4-k Qcn m rrN
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: nn
Owners Name M an A�j
Address & Phone Cu P-4m 4 A, iZ Q 171�► �4 d
Architect's Name
Address & Phone f
Mechanics Name Fir-S4 Cho«t oOU L-1- C
Address & Phone �� �111a-{} � aeUsrl•� ( d"N `r 31L
what Is V*purpose a txw did?
Material of hallo ty? lk J CsC G If a dwelfiN,for how many WOW
wW brrild M conform to law? V'eS Asbestos? tV (L'-)
Ed kn"coat l 7i 5 coo. car uoense s N P, state uovw r C S;'S 1 Z CS
aurae Iapraw k e4X M r
Lic. �° X atu of AV-libant V
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
F} DD �c f3fl'fhre��� e� ti )0L Fl ao(Z
[3t�i 2, w j Pc>r- 139fi,-� I w4lI , IoS�T
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MAIL PERMIT TO: I tb + ` S�• $ eV �t �l f>7 g. �� t�
,
No. % �
APPLICATION FOR
PERMIT TO
LOCATION
�5)
PERMIT GRANTED
APP13)6y—FD «.
INSPECTOR OF BUILDINGS
f
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 Legit
Name (Business/orpmzation/Indivldual): �Pr+ Ckca7Ce
Address: Cl? V716,14 -SL C
City/State/Zip: gt,v a r-��t1 M&, 011 tt- Phone M 91 ff I Z2.3 94
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).: have hired the sub-contractors
2.El am a sole proprietor or partner-
listed on the attached sheet. t ❑ Remodeling
ship and have no employees These sub-contractors have 8. $0 Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'cornpensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. l
Insurance Company Name: S7 ' paqalGmS G
Policy#or Self-ins.Lic. #: (`a 14 913 LO "I—Q57 Expiration Date:: 1 0
Job Site Address: 3571 L ljl� -4 t City/State/Zip: W trn., I't 1
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 insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above Is true and correct
Signature: C Date:
S�
Phone#•
Official use only. Do not write in this area,to be completed by city or town ojfcial
City or Town: PermitfUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M.
lniormation ana instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their'Iernplbyees.mr i
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 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 ibereto 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'iusurance'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)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 require140 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 retumed 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 Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lime.
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 affidavif 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 er the pmivlicense 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 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 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 hike 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 f. ,-
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 5-26-05 www.mass.gov/dia
MA'7-10-2005 10:15AM FROM-Phil Richard ITS 9787741318 T-335 P 001/001 F-326
ACORD,N CERTIFICATE OF LIABILITY INSURANCE °ATEIM 5110/05�-
ML°
PRODUCER THIS CERTIFICATE IS ISSUED ABA MATTER CF INFORMATION
Phil Richard & Associates ONLYAND CONFERS NORIOHTSUPONTHECERTRICATE
491 Maple Street HOLDER,THIBCIERTIFICATEDOES NOT AMB1D,EiXTeMOR
Suite 102 ALTER THE COVERASE AFFORDED BY THEPOLICIS {BELOW.
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NsuR® Beverly86-88 11MAtat 01915 - R�G'8t�,... Paul Coa_ ---
INSU_RERD;
COVERACIEB WSURER E'
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ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 199UE0 OR
MAY PERTAIN,THE INSURANCE OWN MAY BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E)ICLU61CNS AND CONDITIONS OF SUCH
P BEEN REDUCED BY PAID CLAMS.
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IN :.-.,,..AGGREGATE LIMITS SHOWN MAY HAVE ^,
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DESCRIPTION OF CPIRATIONS I LOCATIONSIVEMCLESI EXCL UBONSADDED BY END ORSEMENTI SPECIAL PROM DNS
CIESTIFIC ATE HOLDER CANCELLATION
SHOULD ANY OP THE MOVE DESCRIBED POLIC19266 CANCELLED SEPORETHE EXPIRATION
DATE THEREW.Y11611SUING INSURER WILL ENDEAVOR TO MAIL 15 CAYBWRITTEN
First Choice Construction LLC NOTIC6TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURB TODOSO SHALL
86-88 Elliott fittest MP096NOOB A NORL OC ND UPON THE INSURER,ITSAOENTSOR
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