Loading...
29-31 LEACH ST - BUILDING INSPECTION �L111t16iMliSt�E f#Lei)l D APPROVED BY T44E JdSPJ:, im PRIOR TDA.PEA�IT AEINO GRANTED CITY OF SALEM No 3�- 6 '�\ � Date s: Is Property Located in Location of ` the HWoric District? Yes_No Building Is Proparty located in ;r dw Conearvetlgn Area? Yak_No� BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace. Other: 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: 1 ,� Owner's Name �`res�oven V `'l U �k\Q wQ Address & Phone =L A-Z'*C� S7- ((/7 ) 6S(-a7 5-- Architect's Name OC j n-et-z— Address & Phone ( 1 Mechanics Name j a h u PYL—'� Q r - Address & Phone E 12a Void VI // r`�' - J n�-4,, Mh Z(L— a whet is the purpose of bAding? in�� ( Malarial of buildirrg? iia clic _ II a dwelling,to how merry families? ww building cordorm to law? 7)0E]g:C Asbestos? IVA Estimated coat /Or hod City license• N fa state Licence M D 6/0s-2 g�. 'wravpent K Lia. t ature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: No. Z APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED Jia 6e2 Zo 2-0 APPROVED CTOR OFUILDINGS F 'U.LIO'1101L1{'Ir ocrA2R aw } 12011M001w M 11M9W 340 FL"o ONAM MA0101J0 T1L(jN07wN340 sTAli�� 0. JOL n�ow.aDe�u�nmAv�r ti wela.o.vts�2 pod2Sar df�'i.M!K t 2dM21r11�1f2t 2�.aa1/Ifo� dflifIML 2jllslr ieire..�lei.raow.a(ea.e�lyr rn�2tter+r I 'I .A.�r11..w.e�.... '11r�A���drt dlY�OlOr AnlsW DMS F=T aaepkb dke baoluWAM MINS aqJAsPSWCLSU ) Was w7com Adb%CIVA She ibarAsuwt"*"add"fas&Idmwmbkrmwgkft mwagoow Ala dw dr ft2 o�b�ildflq sY1poM1 � owurmWy IoW.lv2ier &d*Al 4WbWtiY MM dl&SISK ad dW ofa �ador�bada.d� r� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let=_ibly Name (Business/orprimattowIndividual): Cy`-�J d r2 'l iWCn Address: nn ' 7- k�— d, Jt— City/State/Zip: SGc-�-ci� �� - Q � Phone#: G� 2 Are an ou employer?Check the appropriate boa: Type of project(required): Y 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and/or part-time).' have hired the sub-contractors 2.D9 I am a sole proprietor or partner- listed on the attached sheet t ?• ❑ Remodeling ship and have no ernployceg These sub-contractors have S. ❑ 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.❑ Electrical repairs or additions required.] officers have exercised their 3.[� I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. (No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13 El Other comp.insurance required.] +Any applicant that checks box#1 must also fill out the section below showing their worker'compensation policy informatron.' t Homeowner who submit this affidavit indicating they me doing all work and than hire outside contractors must submit a new affidavit indicating such. tContractor that check this box must attached an additional sheet showing the name of the subcontractor and their worker'comp.policy information. I am an employer that Is providing workers'compensation insurance for my employees. Below Is the policyand fob site information. Insurance Company Name: Policy#or Self-ins.Lic. #: p Expiration Date: Job Site Address: ��7 Zr°E rk City/State/Zip:��'/��/.f t� 77)4 Ol f Jd 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 terrify u he enahies that the information provided above is and correct S' a-- qq Date: ✓0 1 � d-7 Phone# Q(Jleld use only. Do not write in thin area,to be completed by cUy or town o, kid City or Town: Permit/I.icense# Issuing Authority(circle one): 1.Board of Heakh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: lmormatiuu auu jul3t11 uiivl<I<a 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 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 employers. 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 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 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 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-Contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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 sips and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or licence 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 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 regarding the applicant Please be sure to fill in the permit/licence number which will be used as a reference number. In addition,an applicant that smut submit multiple permivlicense 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 kwations in (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 like 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 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 wwwmass.gov/dia s } {ji _ t f i Y r " � 1 •F 1 a/ 1 Ij 40 IM IV I �. , " %: a r y APPROVED \ Subject to approval b§any other St uthorit>having,unsdiction. - C.T`_' of S`TEM, MAS3. 1KIZ nn.EtVIATTT(Py l TtTt - U 1 l� 1yCA9r�P P LA 1.PROVEDS _LY FOR 106IMFICai D7 OF 7TYPE AND LOCATION FIRE PiaWT TW C"ViCES. [ � " - { t .a I' } + '•.' IA�L;FIRC PROTECTION DEVlCrc . =EJECT I'0 A r r _ ? s � I F,��'J 1 JFINALTEST AND INSPECTION,FOR COMPLE7E C07dPU- .,. jNC'?IITX TH5'MF i`COF 33 t „ I r ' i F 1 � CJ IN r: IPV Nk p� 1 APP 0 i D O ( ©S Y -' Subj t t0 approval by other Ir - i; auth it-, haven jurisdiction. f ° 3TC Of.S!IBM,M_,ASS. By `\41.Ak3 A4LAPPRbYED SO FOR fOEiiYiFla uN OF ;N - �\ i - > °., e LOCATION OF EIRE FMDTjEGTM C:V!CES. j. I - iI . ' - ♦. 'RLI.R [PROTECTION DEVICES q,._ Ce. Ju.1f0 A 1 4 1% ( . 'i _ �• VI ALT}.ST AND INSPECTION,FOR COMFLETE COMRL!- I i ANCLr WITH THE FIRE CODE. y t4 I s - . . ��