2 LAURENT RD - BUILDING INSPECTION v
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Psfi11K t0: YU LDMIO PEW APPLICA M POR:
Ods MAlid~spW) ROA . kwa sorbs crOflNuw a0k. SINdL P004
PLEASE PILL OUT U& MLY&COMPLETELY TO AVOID DELAVG W PROCESIPM
TO THE UrBPECiOR OF BUILDINGS;
The undoraipnod hraby appin for a permit to bold awwft to Ow kdw#*p
01N Ws NWO 47li'i e'W )• e' L��' l f
3 5 Addnsa 3 Phona
'o Amhk*Ws Name
Address 6 Phone
Mftwics Nona
Address& Phone JCF f r
Moot a OuWiip4 q,br how m"%wAw?
MAN huldrw
Eaylnr�d COr��ems) UO�fro i N A. sm umm•
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MIONED UNDER THE PENALTY
DESCiIIP nON OF WOW TO a DONE of PERruRY
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MAIL
rGfW ,yam
No.LLFOR
PERINT TO
LOCATION
PERMIT GRANTED
POPECITOA OF BIJIIORM
Depornrunt of lndwsWd Accidents
Of'Ice of Inwsdsa6m
F 6" Wislii& ore&Wd
Boston,MA 02111
tvww�awssto•✓dGt
WorMnv Conpenudon Insurance Affidavit: BWMenlContradorsMecb idas&ftmDen
Th.
Applicant Informal (� 1
Name
Address' /S.3
ciws ,� � Phone
ia nrn�t l��;��
7�mn
oyer?Cleett6aappt'oV�bom of Project ��
loyer coif). 4. I am a;mad counclor and I 6. New eonstmction
(All and/or par4t®e}e have h$ed�e tobaoauaGms 7 Remodelmf
Saved on the amcaed+hat=
pmprietar or Parma- Thera mb•contracson have S. ❑ Demolition
ve m emploYces wwtas coaqanattce.in 9. ❑ Bailmg d addition
wodit for sue in S. O we are a corporatia 10. Ehxtrical npabs amid its or additions
(No: right of
oonrp. of&as have eae:cised their
II mu a bbmnwwm doing all wort
r of exemption Per MGL 11.0 Phtmbm airsg rep or additions
3.Cl _ , comp: .y r 132,{♦1(41 and wehaveno 12.0lioofrepair
insuia�e requsea)t cmpk"m (No wodm' 13.0 Other -
comp.imu nw required.).
•'H0 mPP>�tiff c6b,., t a1 mM�bo 50-cut y m do tidowm mrs L6s aAgb• m�aho�a mom'eve i s mk
lgomeowsacvtioot�oit4iNffidadWcb &iftY doh
rC®tr�cton Pou(chaet mintwe mut ahebed a Nddiaaod drat thovmK t>fu of er abwutealutti od>beir wttsaw oaoP taY io&rmdiod
I so an e0yaloya tkmY b pvv4&s workers'comtpenmdom k"remerfor sty tatpioyces.
Below it*#poNq wdjob aHe
orstmKea , /
IanuanoeCampanyNama: - , .. ,
policy M or Sdtim Lin M %5�) = ���' Expiration Data
n9
Job Site Addtw: �,LA z��� �� �0 /c, ,� / . �, ca�y�smoe�ew:
Attach a copy of the workeW,con*msld a polk7 derlarmdm par(ShOwig the P09 number mad expiratlosa date)
Fagan oo some coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cr�aat PLamp of a
fine up to$1,500.00 and/or one-Year i Vpnsa awell m civil penalties in the Amu floe
a STOP WORK ORDER and a e
of up to$250.W a day agaimt the viobsor. Be advued that a copy of tbis swcmemt MAY be Anwarded lo dw Oftc of
Imerngatims of the DIA br insurance coverage vailkAdO .
I le knebj est*gala the pabu aml pex&Wa 0040My tlYss tlFe 6tjaod/ar orovlltl+hour b ass mml eorrres�
r �v 7ZJ ;
ojkAd uw ambt Dr not w►dOt b tAb ene,b br eowpJiArl b1'cAD'aAotws o,�Jeld
Clty or Towns hrmWUeem N
Issuing Authority(drele one):
1.Board of Hemh.Y L Building Department 3.Ckyllowa Clem 4 Electrical al ia S.Plumbing Inspector
&Otter
Contact Paws: Phose tt:
Massachusetts General Law$chapter 152 requires all employers to provide workers' compensation for their emPloyecL:
pursuant to this statute, an anwhya is defiood at"...every person in the service of another under any contract of Ikh%
: ..»�.•expea:er-lmrphed,Otd:O�awt7tt�a� ....j
An emplayw is defined as"an individual,parmasbip,assowatim%porpmatrm or orha legal entity,at any two or ntoro
of the foregoing eapted:in a joint atapise.ad inclodiag the legal rep me tativa of a deceased entpbya,or the
receives or tsaAes of an indn[iohral,parme shq,asmadoa or other legal entity,aWbymg cnployea. however oho
owner of a dwaltiog house bav>nt not more ohm throe Vm mess and who real thoaei4 ce the etx$rpsat of the
dwelling house of smother who eaVbys persone to do maintenance,construction or repair wort on such dwelling house
or on the pounds or buildiag appmteomt thoaelo shall tut because of sash cu pbymat be darned to be m aopbya."
MGL chapter l52,12SC(d)shoo atria that"every date or local Bceadq agency mbar wkbbold the Icons"or
ressewd of a>kense or pamk to operate a budws or to eoodrod boddip lit the eommoowedtb for my
appocaut wbo but not produced wccptW*evidence of compliance with the laaraaee coveralls required..'
Additionally.M%chapter 152.JZCM states"Neither the commmweahh mr my of fd political subdivisions altaII
onto into any contract taw the paftmance ofpublk west=0 acceptable evidence of oompHance wish the insurance
rapkemeats of thu odvpta bave ben presented to the eomttacdng mt&m ."
Apptleaab
please fill out &a workers'compasation afffhvk completely,by cbecft the boxy that apply to your situation and,if
oeorxsay,supply nab co> os(a)name(s),addresses)and phone tmmba(s)abM with their cati8eale(s)of
iosarsoco..Limited Liabfl,*Companies(LLCM a ty I imimd Lial Pumaships OJA with no employes otha ohm the
mm*m or param% are not rev wed to caM wo*='wmpmmdm immmoe. If m I.I.0 or UY don have
employee,a policy is required, Be advised and this affidavit may be submitted to the Department of btdustrfal
AoMc"fir cm&msdm of b mince aovesage. Also be sure to sign and date the affidavit. The affidavit should
be returned m&e city or town slid the application for&a panic or license is being requested,not the Department of
Industrial Accidemt.. Should you bave any questions regardieg the law at ifyoa are required a obtain a workers'
compensation pol y,please call the Depaammt at the nsmba listed below. Self-immed companies should cow,their
self-insurance&Cow66m6a o u fiie appopria0e>'me.
City or Town Olsdali
Please be sun that the affidavit is oumnWIM and printed I%%Iy. The Dgmbncnt has.provided a space at the bottom
of the affidavit far you to M out in the event the Of im of Investigations bas to contact ycm regarding the applicant.
Please be sure to fill in the pamiWceme ttmtba wbid will be used as a reference mamba. In addition,an applicant
that nut submit multiple Pcmvlcem APP&SUGGS m any given yea,need only submit one affidavit indicating current
policy mformatron(ifwcmwy)and soda"Jab Sim Address"dw applicant should worts"all beatiom in (city or
town}"A copy ofdw dObvit 00 has been otBcieft gutted az.marked by the.city a town may be provided to the
applicant as goof slant a valid affidavit is our file fan dame permit or Hcroses. new affidavit most be filled out each
year.Whore a home cranes or cid m is o> abiag a liceme or permit not related to any business or commercial venture
(i.e. a dog license or petunia to buin leave etc.)said person is NOT required to complete this affidavit
The Office of Investigations would hIm to dmk you in advance for your cooperation and should you have any questions,
please do aot 3aiWe W give ns a'call.
The Department's address,telephone and fin samba
The Commonweafth of Massacho tta
DeparWM of Industrial Accident
Whirs of Invetttlgatlong
600 Washkgton Sand
Boston,MA 02111
TeL #617-7274900 eat 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2605 www.mm.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9848
Salem Building Deaartment
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) u nIII
r
` J
Signature of Applicant
Date