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7 LORING HILLS AVE - BUILDING INSPECTION (2) I If r/"sosToE .rNG WIOVED BY T44E IWZC=PRM TD A.PEW BEING GRANTED CITY OF SALEM No. yob \ Data 1011110 Is Profawty Located in Location of Lop IN� Nt1 Is mt are t'Y A&owdct? Yes No ✓ as I"m Is PmMty Located in do Car eammon Ana? Yes No �! BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace. Other: Ci 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: Owners Name C�c2 o Sy ts"t�c7 rz �A rz k� 1�1 u s t �v Address & Phone :T LoR-kr'i 1V%LL.6 NJ C- ( ) Architects Name kpi T A4 E-xz 1 Nis FL:--N M"i I Pc- Address & Phone ?-4 y 6 21(!5 r4--I'D N 40E jC- 1'1j --TbZ - O 8 S� To N Tt#I,-- Mechanics Name ' Address & Phone WtW is Ina p mpcae of t D? m"W of b A ttp? N n a dwa ft,for row many farnim? N WN Wddnq cordorm to law? N I Is,, Aabutos? �j �pc EdWoled coat 100,OoO.t9U (My Limm a IJ A. state Uce tae_r o 2 8 Bowe improve=at Lie. i �"0* 0ure of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE -ty- ��o Q1-10 tQ A NT!:) P.-'Tn OGL I NJ cn CNP goo sF. o MAIL PERMIT TO: K ELF s;I i t:i2 CoNsr. air`: TosE KI{}5c l M c ) b 232- Essig Sr `6VJ/ 'e t_ `f 0 l a 1 -J� No. 1� APPLICATION FOR PERM TO 1�fiitto d /"W-L tft n� cS�P-GE LOCATION PERMIT GRANTED APPROV D 1 OR OF BUI S A as wrap�q,��q�R ill�'DIi�1+oDR R�aD w"pip --- w�or Ali A4c•��wv -VW f.zr( 'All a� ��vrs�t�ni=svri� i� ' S/ • 0/ �s-•wJ '''�alla�' o�A b�+1 7'� a ✓raG7 Sa/1qt�� VIP wwou �4N— — 4rl / ��iwi�v4M0! AA■�li*l0�7� MAYOW AD7rf0m w �sa��i►s�r�as o�c-a�iv °i��s�►�'i�s�� ay "Gs+w �v� asss�e"�w NannNnw►os1 t�+sw+w�so�s�or�ar�nr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers Aanticant Information f y^ Please Print Les_ibly Name (Business/organization/Individual): Address: 23 Z CS (9+' City/State/Zip: V-1e y er lye A��Phone#: R 9 2 • �� Are you an employer? Check thappropriate box: Type of project(required): 11 1.5�rI am a employer with / -t> 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time)." have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. $ 2• ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ 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.[3 Electrical repairs or additions required-] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance requ red.] Any applicant that checks box#1 must also fill out the section below showing their wokets'compensation policy information: t Horneownets who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such IContractots that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'corm.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and,job site information Insurance Company Name: ST' Qu"� �� LEr2 S Policy#or Self-ins.Lic. #: 7 PJ LA -q q -7 K 157- to -O S Expiration Date: 1 I 0 Job Site Address: 7 L Z7 I N Cr LLS >40£2�l L(t City/State/Zip: �L Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Faihlre 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 D1A for insurance coverage verification. I do hereby certify er t pains an penalties of perjury that the information provided above is true and correct Signature: �1(m � e Lr CM.t Date: 0 i $r P / Phone#• %�� 7i 0 D 0 U Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person — Phone#: Information ana instructions 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 in legal representatives of a deceased employer,or the in a joint enterprise,and including the e of the foregoing engaged ) rP g ga ep receiver or trustee of an individual,partnership,association or other legal entity, employing employees. 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 conrrrmonwealth 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(LLC)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 sign and date the affidavit. The affidavit should be retained 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple periidlicense 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 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 76-05 www.mass.gov/dia