5 LINDEN ST - BUILDING INSPECTION (2) Dab
of
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p � NUILDW PERYR APPLICATION FO
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pApaldfloplaw
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PLEASE FILL OUr L.EONLY i COMPLETELY TO AVOW DELAYS N PROCEfiWG
TO THE INSPECTOR OF BU LDINOS:
TNa undaraosci hw* applies for a pormit to build acoodq to the LoMowirq
Ours N m.
Addmsa& Phone ,�,'rID�J� S'� f?ri 9?V
AMhk@Ws Name
Address d Phone
Mso mft Nanw T 6 tf (!:r- 0
Address s Peon. 69 ChAV-EAD6 N ZZ
war�w v�•vo••a ouYtllrq! �W E LL, ly � �
momm a b~ 0 d-o I a ararrq,Iw now wavy ramlrs4 Z 2tWt)
vm k"w F A -H m a wrr c- S Aft~ A/0
aawww oW '�o 40ro coy Uo • N �` aw uo.N.•
SIGNED 1MIDEA THE PENALTY
DESCIWnW OF WORK TO U DONE OF PNWJRV
292
MAIL PERMIT T0:
SOMOI 8 d0 SI
TW=
NOLLVOM
of JMWJM
mcm NOI.Lvorlddr
Department oflmfuatridAceidlents
Offlee of Imrstliadtdons
6" Waskinaton Sired
Boston,MA 02111
lvw►r<neoasaotdd6a
Worker'Compemdon Inmate A Wavit: BngdeNContrutor$Mecbidawil?tu ben
A n fMadan Pleaw Print Lezfl&
Name:.
Address:
Are you as employer?Chak the SwWide boa: Tree of pre jeer(r'e9uirem:
1.[] I am a employer with - � 4. I am a general contractor and I 6. 5N aouvoction
bYyees(SmB anNorperrt-dome}r savehi�edthe sob-ooatrad�f 7ffladj �g
2. 1 am a Idle p1wict"or parma- listed su doe it a cio sheet
shy sad have m employees , Then sub-eontraclms have 8. O�lidon
coo ad forme m any capacuy' wo:IDW comp.nitaranc 1 9. >�dmg addition
wan tv ins 5. 0 We we a corporadoa and id 10.0 Elocuical retain or addkiom
offioen bave exercised rhea or addidom
3. 1 ffiuked.1 b6m ere:doing all work ri>itit of exemption per MGL 11.0 Pblmbiog rgahs
myself: [No wail en' comp c: 132,11(4�and we have no 12.0 Roof repairer
imocaox re4aired.)t employees.
yees. 13.0 Other
one requ¢ed].
�AnY epplicot deg chub box rl mot do®mLL�eater below dwafoa wwtds'eonymadOeraud m6xm�a .
tHomnowwa�combo�W8Sgd *hdiuthia&Wm daft AwaleadamhitsQUW*wonmwswhen§.rnow��vitb&Etina,cosh
Vanoawndot ebo*tim boat mug uu"m add dwd,but Awing do new of do wb-c�ad dwk wadme'eamR Poa9 iatbrmuaoa
I am sm estploya Am is pm*tnf workers'eomprnndos hu reme for sry eaployres. Below As&I poilq nut Job sflte
Aefsrwgtlra
bsmmce CompanyName
Policy p or Self-ins.Lie,N Expi adon Data
Job Site Addttns ciwsuwjzip'
Attack a Copy of the workgW,Compa don poky dedaratlon P14 P(showing the Pommy number and eMdratioa date)6
Pallme to sccwe coverage at required under Section 25A of MGL a 152 can lead>D the imposition of criminal penalties of a
Bee up to$1,500.00 and/or one-year kVwOnmMX s wells civil pe saities in the fo m of a STOP WORK ORDER and a fine
of up to$250.W a day aping the violator. Be advised that a copy of this statement may be forwarded tb die Office of
Invadgadome ofthe DU far Woraooe eovwp vaitkadon.
I de Aerrby er Pew a d finafter ofPffJwY Liss lsfrnm *xp wi&d above k tlsw amsfmt
i
1Z z/ DS
O,�'lelsl ear w6t Diu sot wr&As tk&tree,10 it eowplrarl by dV ortnmvs o fldd
Cky or Tom PermNueeme tl
Isaing Authority(drde one):
1.Board of Hakh L Building Department 3.Cky/I'own Clerk 4.Eleeb ieal Inspedor S.Plambing Inspector
6.Odwr
Coated Person. Phone 0:
Mauachusens General Laws chapter 152 requires all empbyea tD provide workers' compensation for their employtta.
Pursuant to this stamtev an emp/ekyee is&Ancd as"...every person in the service of another under say contract of hire.
express or inptied,and or writam"
An awpbys is defined as"an individual.patmership,also cogmadon or other legal entity.or any two or more 4
of the foregoing dolind in a joist eoaaprite,and including the I*d npnsestatives of a deceased eaployer,or the
receiver or.tnatee of m indiyidttd,partmersbip,association or other legal entity,mWbywg employees. However this
owner of a dwelling house having not soon dism doe aparuncom and who resides therein,or the ooapaat of the
dwelling home of smthetr who employs persons m do mmaenmoe,co racoon or repair wank a arch dwelling home
or on the grounds or buildfag apputtensns dWW Ad not because of such employment be deemed is be an etmploya"
MGL chapter 15Z 12SC(6)also sma that"every state or kcal Yeeadg sptesq she/wdthhold the hmsm"or
renewal of a Heeme or permit to operate a business or to construct bafidbrgt is the eommoewedth for say
appmeam.who has act produced acceptable evidence deomptismee with the insrasa coverage required"
Additionally.MOIL chtpta 15412XM stges"Neteser the commonweabh ON asps of its PObdc lsubdivision$2W
enter into any conaaot fins the perfosossna ofpublk wok until aamptabk evidence of compfiasax wilt the immamos
ngniremmo of dtu dmptw bave been p acnmd to ie oontrscting authoehy"
A"Ncmb
pkase fill out the workeW compensation affidavit completely,by chug the bozes that apply to your situation and,if
necessary,SWllr sub- G)name(sb address(es)and phone number(s)along wies their eatifieate(s)of
ma rsoce..Limited Liability Compavia(LI.C)or Limited Liability Psrtomb s(LLP)with no empbyca other Chao the
members or partners,an not ragaved to cary workers'compensation issuance. If an LLC or LLP does have
employees,a policy is required. Ile advised that tins affidavit maybe submitted so the Department of Iodustrisl
Accident.for confirmation of iamrance coverage. Also be sure to alp and date the of idavlt. The affidavit should
be rearmed to the city of town that the application for the permit or license is being mpeated, ant the Department of
Industrial Accidents.. Should you have my questions�'fa die law ace•if you an required to obtain a workers'
compensatim po$ey,plem all the Daps unm at the number listed below. Self-roared common should eater their
self-insurance H=w i mnber on the appsopii ae lime.
Cfq w Town OfHetahi
Please be are that the affidavit is complete and printed legibly. The Deparnmect has provided a space at the bottmn
of the affidavit for you to fill out in the event the Office of Investigations bas to contact you regadmg the applicant.
Please be tan to fill in the pami0keme nmoI which will be used a a reference somber. In addition,an applicant
that most submit multiple permWhccm applications m any given year need only submit one affidavit indicating arrant
policy information(if necessay)and umder"Job Site Address"&e applicant should write"all locations m (city of
maw}"A copy of the of 1davit dips has been officially stamped or.umW by the,city at town may be provided to the
applicant,as proof that a valid affidavit in on file for metre permits or flea A sew affidavit most be®led out each
year.Where a home owner or cities it obtsi ftis license or permit not related to my business or conmw=W vmmm
(ic a dog license or permit so burn leaves etc.)said person is NOT required to complete this affidavit
The Office of investigations would hlte to than;you in advance for your cooperation and should you have any questions
please do not heaitale b give m a all
The Deparm=Ws address,tekpbone and Zia number
The Commonwealth of Massachusetts
Dgwtmeat of Industrial Accidents
Office of Investiptiom
600 Washington Street
Bost.MA 021 I t
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-OS www.mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. U90VICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildinfl D De artment
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:
fZ-- (Location of Facility)
I
Signatur of Applicant
/2 zj pS
Date
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR.
Ntirntr 068807
B' -u,- f945._,
07 Tr.no: 8778.0
R
JOHN J VAR GO
65 CIARENDON
1t LYNN, MA 01902 C /f
i - commiretonor
t 4 .
Board.of Building Regalatians and Standards
' HOME IM R�OVEMENT CONTRACTOR
_Registratforr.\123738', .
E .at 4/8I7�007
nd vi�dual
f( FI
. John J.Vargo ,t..
John Vargox
65 Clarendon
Lynn,MA 01902 �"'�