79 LEACH ST - BUILDING INSPECTION fL�1161A11fit�Ef NiD �PPROVE(D 8Y T414E
JdSpFGIOB PWR TDA.P03111T WING GRANTED
CITY OF SALEM
Date
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, ROMA Install Siding, Coratnxt Shed. Pool.
RepawPAPIM. Oltt w - ®moo
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDING&
The undersigned hereby appim for a permit to build according to the folbwmg
specificabow
Owners Name /�' ` ^'- od„ -
Address & Phone 7�i ����� s� (y7� 1 7�/N L27
Architect's Name �nn�
Address & Phone
Mechanics Name 97
Address & Phone F-7 ��i�,,/ (i (47F 1 /S -71
wnu n an pWpon.at otrmrp?��..c o.v�r�•. � ,��
MMM of WON? Ir a dww",for how many WnWin?
Will bAwq wivorin to law? vo _Aeb."? A -,'u
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Lie. # � o
pnatufeof AppWnt
SW= UNDENTHE PENALTY
OF PWWRY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: ���
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APPLICATION FOR
PEM I TO
LOCATION
PERMIT GRANTED -
A7 OVED
V-
INSPECtC9 OF BUILDINGS
4
The Commonwealth of Mgssachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Elecctti lumbers
Pldpta�Print Legibly
Applicant Information
Name s0rgaoiration�lndlvidual):
Address:
City/Statx/Zip: Phone#: /--e�7�
box: Type 0(project(required):
Are you as employer?Check thrappropriate4.,.❑ I am a general contractor and I 6, New congruMu
1.❑ I am a employe+with • have hired sub contractors
employees(fun and/or part-time). 7. ❑ Remodeling
listed on the attached sheet t
2.11�I am a sole proprietor or partner- These sub-contractors have 8.demolition
ship and have no employees workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity. 5. ❑ We are a corporation and its
[No workers' comp.insurance officers have exercised their 10.❑ Electrical repays or additions
required.] i 1.❑ Plumbing repairs or addit►ona
3.El am a homeowner doing all work
right of exemption per MGL
a 152,§1(4),and we have no 12.❑ Roof repairs
myself. (No workers comp• (No workers's lempoyee .
insurance regrind•]f 13 Other f./r(tdlN�, Ific
comp.insurance required.].
�MY applicant that checks box#1 mire[elw fill out the section bebw dtolmg kicky waken'eatWen otm policy mformanon:
i Homeowners who ad cat tba of &vst m&ea mg they an dame all work and then but outside conhacten must submit a new afrwvit mdimtins such
%Convacww that check this box must attached in additional sheet showing the carte of the subconnactan and their worker'comp1 policy mfom"Ion.
I am an employer that U providing worke co n htsurame for my employees Below Is the po/!ey and job sfts
Information.
Insurance Comp=y Name:
Policy#or Self-ins.Lia#:
Expiration Date:
Job Site Address: City/Statc/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or ono-year imprisonment,as wen as civil penalties m 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 herby ce r the pains and ptnaltles of pedwy that the information prmWed above is true and correct
S ` D oS
#: e S .7
offlel 1 use a* Do mat wrde/A this area,to be completed 0 c6y or town o,Q'lelaL
City or Town: Permff/Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
1111Va aliN 6lVal Nllu 111061 ►1�.61V110.
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 iodiv"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 tmstee of an.individuak partnership,association or other legal entity,employing employees. However the
owner of a dwelling house Laving not more than three apartments and who resides therem,or the occupant of the
dwelling house of sandier 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 stairs 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 commonweal nor any of its political subdivisions shall
enter into any contract for the performance ofpublic 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),addresses)and phone numbers)along with their catificate(s)of
insurance. Limited Liability Companies,(LI.Q or Limited Liability Partnerships(I LP)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 affldavit. 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 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 permitllicense 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 locations 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 fer tiiture permits or licenses. A new affidavit must 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.e.a dog license or permit to brain 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 face number:
The Commonwealth of Massachusetts
Depa=ent 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 5-2rros www.mass.gov/dia
0
CITY OF SALEMIp MASSACHUSETTS
Kim R 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:
&1e 1,'4e (Location of Facility)
Signat re f Applicant
As-
Date