3 LEMON STREET CT - BUILDING INSPECTION i
Na
APPLICATION FOR
PEM I TO
LOCATION
PERMIT GRANTED
7( Dl�5 19
INSPECTOR OF BUILDINGS
r
'PLwN8mkw49Eq%fi"ND APPROVED BY'Re
MPECH PRM TO A.PEA W REM GRANTED
CITY OF_SALEM
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MN WModc am"? Yes Np i•ooatioa of
Is Po"m my LocmW in
ft CaMWVWapn Ann? YQ No
Permit t0: WXL IWIG POWAPPUCATION FOR:
(Chle whM wr apply) ppRoo�d,,��//Rppo�ma�t,,.,�ln@W Skam. Conte Dock. Shad pp'�q���^y,'
"e1��•'�, Other: /r ,h t O c%G w� �i5'�Tfl/CDaiuS"
PLEASE FILL OUT LEGIBLY E COYPLEMY TO AVOID DELAYS IN PROCEsgWQ
TO THE INSPECTOR OF BUILDINGS: .
WOW WON for a permk to build aaooni',ato the.Wiftkp
Owner's Name
Address A F hom 674 1 5-4. / 444f 1d
Architect's Name
Address d Phone ( 1
Machar iCs Name _ Re4,Z
Address a Phone f' V.,Ac'vi�rd fpe Ld/1 .��/ 7
At iF,
What is the pupm it arbr,o? !1E`_." ",
www a tKrrarq?��m��� � r a ewalYq,ror now aNr�►hniw?
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SWMA of Applicant
SIIAID UNDER THE PENALTY'
DESCiirlPylON OF WORK TO BE DONE Offs PMLRMY
MAIL PERMIT To. zSfu
ueparrmenr of inausmal aeetaenrs
Offlee of Investigations
600 Washington Shed
Boston,AM 02111
www.faosagot✓dia
Workers'Compensation Insurance AMdavit: BuNders/Contractors/Electridans/Plambers
Aoolicant Information Please Print Leeiblr
Name ` L'-, ,e
Ad&ess: 02 Ffl%/c7 v/ t w 221 dt' ,
City/StaWZip: A/t FfLdCry 421 ' VPhone#._Z
Are you an employeet Cheek the appropriate box Type of project(required):
1.❑ I am a employer with 4. ❑ I am a,geoeral contractor and I 6. [:]New construction
,�Ployed(aln and/or part t 140 have hired the sub-coatnebn
2.M I am a colt proprietor or parmc- bated on the attached sheet t 7. odelmp
ship and have no employees These sob-contrasts have S. ❑ Demolition
world* Lox me in any capacity. workers'comp.insurance. 9 ❑ Build in addition
(No workers'comp,inapt== S. ❑ We are a corporation slid is 10.Q Electrical repairs or addition
r
offices have exercised tick
3.❑ I am a bomecwner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No wakew comp• c. 15Z 41(41 and we have no 12.0 Roof repairs
insarsnu required.)t employers. [140 wofim, 13.❑ Other
comp.Wmanm required.)
•Any applicant dw d wcb box#1 must w Woo fill out the uion below showing fink wo bw policy
f Homeownen wbo submit min efi3dsvit ni ieeton Guy ere doiog all work and then bin outo le eoukacton most submit a row @M&vg iodieaaing such.
1Coutwien met cbeck on box mkt a taehed an ad0mod sheet showing me none of do anbeoomwa s and dm sawkew coop policy mtbnn tam
Zen irk empdoya that b providing workers'compensation bra mmefor ary eetployesa Below bW podry eued jbb sib
bsfortsa*a.
Im urrance Company Name:
Policy#or Self-ins.Lic. # Expiration Date.-
Job Site Address: City/Statd2:ip:
Attack a copy of the workers'compensation policy declaration page(showing the poBry number and expiration date).
Failure to segue coverage as required under Section 25A of MGL c. 152 can lead to the mipositiaon of criminal penalties of a
fine up to$1,500.00 and/or one-year mprisonmen%as wen as civn 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 As hemby cerounder A*pains Dar nahieg��µe ykf proplJed tiro/►�s b sus a/eenees
S i®atate� i Q 4.L1 /d e,�
Phone M: 7 ! / 7✓ 1,j
O lcid use e* Do nor write irk Alt wee,is its comp/slsd by city or mwa gdkid
City or Town: Permltuceose#
Issuing Aotbortiy(drele one):
1.Board of Health Z Building Department 3.Cky/fowa Clerk 4. Electrteal Inspector 5.Plumbing Inspector
6.Other
Contra Peru: Phone#:
em
Massachuseas General Laws chaPa*152 requires all employers to provide workers' compensation for flea�PmY
Pursuant to this statute, an empfoyse is defined as"...evay Pelson in the service of another u�cr any contract of hide,
w f
CWM or implied,oral of w[ittcL
MO 0"mom
An mpiew is dcfhied as as i�ividdial,partnership,associating,aorPonttne or a of eceaead legal ,�PbYa+ tLa
of the foregoioi mgai�m pint entapdiee,and inchidittg the twirl rgpdesemanv
roceiva or idgatee of an individual,padmerslup,association or other legal emity.ca4bY��4bY� i�a the
owner of a dwelling boo"basing�name LLan free �who resides therein,of the ooap>at
dwelling house of another who employs Persons to do malawnsuce,consuncdon o*tepees wo*k on such dwefiinLL bonne
or on the god o*building thaelo shall not became of such employment be deemed to be an emPloya."
MGL chapter 152,125C(6)also states*""every daft or local beendag ageney attar witbbw the iwauee or
reuwal of•reeve or Permit to operate a badness err to eoulruct balbla0 tree the eoinmonwcsft f��
dab has not produced aaeptabk evidence of eomprana with the insaranee eo"Mp rW
Additionally.o b"diap produced
¢25C(7)states"Neither the com®omveald►nor MY of its political subdivisions shall
eater into any COn1Dtdft>�haveP
erbMiuc of be work until soceptable evidence of compliance with the bmr met
requirements of this chap b the coniractmi mthont .w
APP
please fill out the workers'comprnsatim affidavit completely.by cmunher the hoses that apply h dick t year situation and,if
neeeaaa y,supply*u-con�o�s)name(sl addregt(as)and pbone nembats)aim With ns employees sother than the
insurance safes 01Q or Limited Liability Pa*lnasl�rys(I LP)
Limited Lin we not
COMP OM carry mac, �hunritum If an LLC or LLP does have
members or parmas, ere notes
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of attid rial
Accidents gee�mation of insurance coverage. Alm be sure to dp and date the aril not the tahonid
of
be returnedm the sty or MR that the application fa the permit or license is being*aNes*e4
Industrial Accident Should Yin►have any vent= mB or if you am requited 1D obtain a wofkeas'
CDmpcasationpobey,plate can the Department at the number listed below. Self-nursed companies should enter their
self insadance license rumba on the approPrift
City or Town Ofddals
Please be sine that the affidavit is complete and printed legibly. The Depatinent has provided a space at the bottom
of the affidavit for you m fill out in the went the Office of lavestigadm bas to contact you regarding the appliccat
Pleau be sale to fill in the peraM iceffie number which will be used as a refaence nembef. In addition,an apples
,,that mist submit multiple Permitfii�applications in any given year,need only submit one affidavit indicating curent
policy information(if neceasary)and under"Job Site Address"the applicant should write"all locadom in (icy of
town)."A copy of the affidavit dhst has been officially stamped or madked by the city or town may be provided to the
Out each
applicant as proof that a valid affidavit in on fib for Must Parma Of tic �n61W my business of commercial venture
where a home owner c#citirm is obtaining a license or permit
(Le,a dog dance or permit to bran leaves etc.)said person is NOT required to complete this affidavit
The Office of Invadgxdow would like to thank you in advance for your cooperation and should you have any lineation,
please do not hesitate to give m a caLL
The Dcpartm F,ems,telephone add fax mmba:
The Commonwealth of Massachusetts
Department of Industrial Accidents
otAce of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax At 617-727-7749
Revised 5-26-05 www.mm.gov/dia
CITY OF SALZMq MASSACMUSSTTS
v PUBLIC PROPERTY DEPARTMENT
120 va(amlmaTon arman. 3a0 Fume
BAa tw.MA Of 070
TEL (970)740-9596 In. 300
FAx (11741)74 -9644
STANLCY A USOVICZ. J&
MAYOR
DISPOSAL OF DEBRL4 AFFIDAVI?
Is aooarda m with the povidooa of MOL c 406 SA I admmWp that as a caad tiem
ot>bWft Permit P a0 dabeis making Am the emoacdcm aetivity
pYmd by this Hml ft Pamsit sted be disposed dim a Properly lieaaaed aolid4vmW
dbgmd bdtitye as dedw d by WIL c 11L SISM
Mw debris will be disposed d at: AA--It`l/ IP /u,47 �-�/,�15� �/l�t,•�E,�.��
Loeatioa ofFseility
SiSubnv otPEtmit Applicant Does
FULLY Camplate Iha Mminj mh mdkNL
(PLEASE PRDrr CLEARLY)
Name of Permit AppHc mt
Fimt Nam%if any
Ad&—1 City a Star
The above statute requires that debris Am the demolition;reaov&UM rehab or other
altastiom of build q or mwture be disposed is a pwpaly-liceased solid-waste disposal
to 2k as defined by MGL CDC, S1 SOAK and the builditq pamits or Hera a are to
md"S the location otthe tad6ty.