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67 1-2 LORING AVE - BUILDING INSPECTION
i No. APPLICATION FOR PEFAfr TO Z /o oL �e-2ovJ� LOCATION PERMT GRANTED v eos f 9, 411 Aar APPTVfD OF OLMLOPM fl>y1S�tlST�EfMlEMID A/PROYEO AY TiIE =F=Mg PWR TO A PP. W.ITEM GRANTkD CITY OF_SALEM No. wwd--__ �oat»et Loomm b Haft ODUiCl4h loaatio� of Yak.No� s.tia� ��d hyd b Plow-f Loomm In .i.CgrNM�oA Mt? Yam No WALDM�Ki PERMIT APPUCATION FOR: Parrtlk to: (Ckoia wdlWWw apply) Rod. F1 0 SWft CiOnWW Dom, $IW POOL PLEASE PM.L WT UMMY a COMPLETELY TO AVOW DELAYS N PROCUWA TO THE INSPECTOR OF BUILDINGS '. hanby applin for a pwmk to build a000 on to on tolwmWq i Ownara Name k C h &rd Ad*maPhone �27% ©r�ycg ✓�V (�I71 �rl — or4/ ConTrnchlZ /' Name e\ • Cis r(-e Co_ ACSTr g 0-to" Co .r yr O/466 Ad*maPhom CJi-(Ker Rom - Madfwtin Name Addmu a Phone whitMvoa•vona r,eS;cQeAc?'PA-1 Mart d tNdldrgt— DID [T N a dwNnq,for hcpw ra.M� w•4+I�o oontone b INn �/'YS �.e..en r�o End oft 4&o,oo CEr LIoNw. a11b L1oMIM. o 5488a 8V*Wm of Appfioarn 8111MI ulmm TIE Ps"TY' OP PSA, m oEscRlPrloN oP w®RIc ro eE DDra: Q n MAIL PEF T TO; uepannrenr of Jnaastnat nccraearS Of flee of IRMS41116na 600 Washington Street Boston.MA 02111 rvwrs�ntossgot✓dis Workers'Compensation Insurance Aflldavft:BWMemContradois/Eledridans/Plambers AvOcant Information Please Print Lef:ibly Name : A-C. CAS-rC2 �oncSl2kc2iy✓y o. Lei Address: ,� W A( K er GQ City/Statemp: f Phone# Aye as�Pby tbe tlpprop box. Type of project(required): 1. am a employ with ❑ I am a ymaal and I 6. [:]New comrtuction employes( and/or parNtime}/• have Laed t>te cab-contraaon 2.❑ i am a sole or paced listed on the attached sheet= 7 ❑ fig ship and have no employes These sub-contractors have S. ❑ DemoMion workfing for me in any caPacuY. workero'comp•imllraoee. 9. ❑ BuilifinB addition [No workers'comp.insurance 5. ❑ We are a corporation add its equirefl of em have exercised their 3. Electric]tepaisa or additiom 3.❑ Iram a bomecwner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. (No workers' comp. a 152,¢1(4),and we have no ME] Roof repairs housince required.]f employcw. [No woikaa' comp inBlranCe required.] 13Other Tr. eAny epplicam dot cheeb loot 0l mot also®out da eeebae blow dowka**wodwrs'oompoomd o po+ey mauaadioa t Homeowners who sibmit fids oA'idevh sodicsfins toy an donq ea work and dm Imo amok wmeame mug submit a now aBSdava mdKat%g Buck tCont sum ffia check this boo me auched m edMonW abort showmil tb name of the mbaoo a and dm*woAcae'wrap.polky mfortttation, law aw employer tkar is provMW workers'compatsadm buwrawee for cry employees Below 6 Om poft owd fob sft Iwiortuadoa 6., Insarwoe CompanyNama Policy#or Self ins.Lie # _C-n5 5 9GQ 357$R X�/o4 Expiration Date: l/ i3 OS Job Site Address: &?Y-1 ).artNs ,4t/ City/State2ip: SA-le..,}1r4 or9'�a Attach a copy of the workers'compensation policy declare tlon page(showing the policy Bomber and esptration date). Failure to segue coverage as required under Section 25A of MGL o. 152 can lad to the imposition of mimilw penalties of a fine up to S 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 10 the OMCC of Investigations of the D1A for insurance coverage verification. I As hemby cero sisd�larAir patio and pewaMa oiperiwry tbaf the Infwmadow p ve rovikd abo b aw and cornea Sim &ea.. P Date 8`Cl—C)s O,Q9clal wss only. Do alt wrbls le tkb area,to be completed by cUy or saim ohkid City or Town: ItermWl leeme# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyfrows Clerk 4.Eleetricat Inspector S.Plumbing Inspector 6. Other Contact Peron: Phone#: Massachusetts General Laws chapter 152 requires all employes to Provide workaa' n nttact o bite. pursuant to tines statute, an empfoyw is defined as"...every, u person in the service of another nder a>ry G express or implied,0=1 or W'" tion ar odic legal entity,or any two or more An en+P�lc is defined an"an inttividual.iMparmcisb*including the le corporation a,or the of the foregoing,engaged ice a joint eatapa he,>�iochuding,the Iega1 representatives of a deceased emp However the receiver or ttastoe of an iadrvidtal,P association,or other legal CoMy,employing,employees of the . owner of a dwelling house baving not Ines than three who residesf repair or then such d dwelling house of another who employs Persons to do.maintenance,construction or repair each dweltimg,hoarse or an the gioumds or building &-ft"not because of such emploYmentbe deemed to bean cmPIOYW" MGL chapter 15Z 125C(6)also states that"every state or toed 8cend"agency did wltlabold the or renewal at a license or permk to operate a business or to construct WOW In the Commonwealth for say appacaut who ins sot Paned acceptable evident of comp8anee with the Insurance coverage"gWred.» Additionally,MOL chapter 152.42SIX7) 'Neither the conmmvcaldh not MY of its political subdivisions shall ��00 the paformsna of public wodt urattl acceptable evidence a of courfla wid,die buornm cam into any o have boa presented m de contracting,antbority" requirements of this chapter APPtleaiNs Please fill out the worlcess' *m atlidavt CO��''by on number(s) die boos that ickb'st yaw situationO fen and,if -�ttactor(s)namds1 addnas(cs)and Phone>mmba(s)along(L with their emi loy=other than the maasary, Limit ability Companies or Lfmfted Liabr'L'tY panaerships(I f an with m emplo es b numbers Panne are not regnrred carry insurance. If an LLC or F.LP doe have members or P to worker'wIDpensation employees,a policy is required. Be advised that ft affidavit may be submitted m the Department of hdustrial Accidents for confirmation of immanee eovaW Alan be sure t0 alp and date the dlldavn. the affidavit should be rcntned to the city or town that dire application for the permit or license is being requested,not the Department of �you ban any questions regarding the law or if you an required to obtain a workers' Industrial o ins iter tmmber listed below. Self insured companies should enter theca compensation on policy"P�call the Depattmeot at n self-insurance tkense monlia on tie le' City or Town Oflldsh please be sane that the affidavit is Complete and Printed lc&br. The Department Las provided s space at the bottom of die affidavit for you to fin out in the event the OMA of Itvestigations bas to contact you regarding,die applicant m fill in the Pere icense mmcr Please be sure o wbich will be used as a refaeoce number. In addition,an aPP� isany given year,heed only submit one affidavit indicating,current that must submit mnluPle P��e applications policy information(if occcasery)and under"Job Site Address"the applicant sbould write"all bcatrons in (city Or town)."A copy of the af5dnvit that has been officially stamped or marked by the city of town maybe Provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit mot be filled out each year.Where a bome owner qt ei&m is obtaining a license or permit not related to any business or oematereW vesture (ie. a dog license or permit to bum leaves am)said person is NOT required m comPicoe this affidavit. The office of Investigations would lulu to thank you in advance for your cooperation and should you have any qumdmia, please do rot bcdb to m give 1112 C21L The Dcparmicurs address'telephone and fa mmrbt3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invedigatione 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mm.gov/dia CITY OF SALRMV MASSACHUSETTS PUaUC PnoraatTv DtrARTmwxT 120 MWNINOTON ST11aaT, 341)FUMM SALtM.MA OI1170 TR (970)7{8-1111M tn. 300 FAR (11741)740-SSN STANUCV A U GOVICl. AL NAYM DISPOSAL OF DMIS AFFIDAM In aoomdsnoe witti the p ovWm o(UM a I%Sir,I sdmowladp that as a cm&dm of sa t Punk r .a ddmk runllim b ra do coadmcdm aetaivity bwmd by Ida Faoait"be Mqm d olio a plopaly lieaored so"araste db*md be fts n debod by UM a HL SIX& lb dob ds will bo dspmad alma AFT- Pe(-)fo o±.� Loeadaa ofFleilitlr B - cl-ds S*Atllla Of Pamit APPlieaot Dde FULLY o mplol s the lbMm ft iahms" OULASE PRpnW CL8AMY/) /{.O.�c Icy 2.4-Ksd�e i 1 Name OtPamit Applieaas !/I -C- c/a-sT-ce C6n.Si �KcTia�! �� T�crC File Names if may A&hok City b StaM The above sesM regwm that debris from the demohuM nmovatio%rehab of odw akasaan ottWWinS or smL-tm ba disposed is a properly-lieeasod soh&wsw disposal 6ah as defined by M(M ca S l5ft and the bWldiop permits or& ma an to iadiate the loesdao of the beility.