9 MARCH ST - BUILDING INSPECTION k Pfgmly LopMd b Loaatim of
omed In
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SIMI.DMIO PERWT APPLICATION FOR:
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(Ckols whWwwr apply) Ra vd, Skft CwW" Oaok. Stod, Pool.
PAPIii
PLEASE FILL OUT LROWLY A COMPLETELY TO AVOID DELAYS W PROCSSWA
TO THE INSPECTOR OF 0 01 INN08:
The urlda @*W hwaby appal br a pwmit to buM ao=ft to Uw bN*W rp
wafts"a.
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M hkelx'a Name W 04 6&0
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ll �—34`��2.'tb' SIGNED iJNDER T1iE F�ENALTY
OF PUMUM
DESCRIPTION OF WOW TO Ill DONE
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MAIL P'ERWT
No.
APPLICATION FOR
r PIMIII TO
LOCATION
PEFWT GRANTED
Dee eneiec, Z/ 2eoY--
A
WOW OF BLALOMIGS
Inc a,atmnvnrrcrw. .q ...�....��.___��
DepartmeW of lndusWd Accidents
Offla of Inves*adons
6" Wasbiwaton Street
Boat^MA 02111
wwwRai ssmVAa
Workers'Compeoaation Inalranee AfMavit: BuBders/ContradonMecMdans'Mmbefs
p
Name Info atio / Page Pri>!t Lego Y1
:
Address
tate/Zip: `� Phase :
aws
Are yom an evower'r Cheek tie'apProprT TYPO utpnjed(req dre�c
1. I am a employer with +. I am a gt�counclor and 1 6. ❑New construction
mnand/orpazht®e}• � `be"likedme y p xemodetinB
2.0 I aamdcuplaIOU rmp�r°t i Those on the attackedclO11M=
These cob-oontraaon nave 9. ❑ Demolition
ship and bave no employes workers comp ietaQanpe 9, pt addition
working for camp in S. we are a corporation add its 10. Electrical repair or addidama
But
[No workers'co officers nave exercised their
igkt rofexempticnperMGL or additions
I ffi ao
3.� homeowner doiai aallwork I1.� Plom1�r�
comp a 15Z¢1(+�and webave no 12g. Roof rWb
mysdE [No wner
insurance ralnii d.]t imtttamce w aired•)• 13.� Otbr
t a wwSIst:Lat cLtcly boa d met tbo Beau fret striae an wakft ed are Luc' apnda• wale mn m�O=bob r ww ffivit i 6csfina ash
t aUvaa=*dcb*&ft�ftM10& L>dieet &d&d a�a
:Caeeedou��dtia Loa mrt atreJtad m tlditlond r6mt dfovift tLa rear off abamtree4a owe*woltaa'hemp PotieY mromstios. .
[nt an
cwPliye that Is
pro►fdmd
in&Urs'carpemm*x Usar""jer an'empAV s• Beier 6 a#Mft ad job ske
nuttranoe Company Names
policy#or Self-ins.Lie.# Expiration Date:
Job site
Addrerr Cwstatrjlfpc
Attack a copy of the workeW,eompan don polky declaration page(d mvwg the Polley number and e:plradou date).
Fa sloe to seare ccwaaae as requited under Semen 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 ad/or one-year Wilbonme4k as Wes as civil penalties in the form of a STOP WORK ORDER and a floe
of up to$250.00 a day against the violent. Be advised clot a copy of this statement may be forwarded to the Office of
lavestiptioes DIA far• coverage verification.
[AV hdMbvfjhgq malty rbe PMNI that [afwararloaOrovfld.bow ante ea�d ern ees
J z 2�
vueee fi q7 4s q 2 7 - 2d y I
v, aml Mar au/]c t>Ie RBI rsdtr In a&one;ar br cowp/rbl bJ CONmaes odlclett
City or?own: PermBrueem s
Inning Authority(drele one):
1.Board of Health L Bullding Department 3.Ckyfrown Clerk +.Electrical Inspector S.plan aft Inspector
6.ONer
Cooled Person: Pkoa#'
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thek employees.
Pursuant to this statute, an sapleyee is defined as"...every person in the service of another under any contract of bfra,
empress or implied,and of wriuma ..
An employs is defined as"sn Mvidoal,partnership,moe OW16 corporation Or other legal canft err nay two or mots
of the foregoing engaged is a joist enterprise and including site hgal representatives of a deceased employer,of the
receiver of transtea of an imdiv kek parmash4,amewn or other lmd co*employing employaa. However the
owns of a dwelling house having ant more than three apartments and who resides i wm*or the ocapaet of tubs
dwelling bouse of MdWr who employs persons ado canoe,construction or r pair work om such dwelling boom
of oar the gr=&or binding appmrteusaat&crew shalt ant because of such empbymmt be deemed lobe an employer,"
MGL chapter 152,12SC (6)alsu states that"every date err bat Yeeadeg agnngr slid wv*hhele tanat+ea or
perm*renwat of a Beene or pm*to operate a budam or to tontred bdldtap In the eommond thwallh for aq
apptleam[who has nos prudtaad aceptable evtdtace deompgamoe wNh tie huaraaoe requsired.".
Additiomaily.MCd._chapter 1529125M states"Neither ibe commonwealth nor nay of to political subdivisions and
eater,inn nay contract Stir the pertbmaooe ofpubec work no&acceptable evidence of eompHaaee wi&the ba nts moo
regairementa of this chapter have bees presented a&e contraelied autthorhy.- .
please fill out the workers'compensation af8dsvit completely,by chectimg the bosun that apply to you situation and.if
necessary,supply wb-contractor(a)naate(sj Wdrers(a)and phone number(s)along wins their cati&aoe(s)of
romantics Lim*d Imbt7ity Compm a(UQ or Li Md Liability Partnerships(LI.P)with no employes other than the
members or partners, an not raju and a cary wo*='compematin imm=m If an LLC or l.0 don have
employees,a policy is required. Ile advised that this affidavit may be submitted to the Department of bdatrial
Accideob fc f cmgm d m of b mans coverages Also be unto sign amd.date the&Mdav*. The aiidsvit should
be rearmed a the city or town thatthe application Pot the permit or Hoene.is being mpeated,ant die Departmeut of
Industrial AcciderAL, Should you bave any Questions reprdimg me law or ifyou are required to obtain a workers'
compeasaboa poW,please:call the Department at So mamba listed below. Self-insured oomphuia should earn their
self-hunn nce license number oa the appropriate lien
Chy or Town Ofliclali
Please be sun that the affidavit is complete and printed legibly. The Department has provided a space at the boom
of the affidavit for you to W out in the event lee Office of Investigations bss a contact you rtprd*g the applicant
Please be sore to fill in the perm WHcnw mamba which will be used as a reference number. In addition,an applicaot
that mat submit multiple permWhmw applications in any given year,need only submit one affidavit indicating an,
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
awn}"A copy ofthe adWavk that has boa o®cially!tamped ar.mwW by the Clay at town may be provided to the
applicant as proof that a valid affidavit is anf k for&are permits or liceoea. A new affidavit man be gilled out ewb
year.When a home owneror cities is obtammg`h Nomse or permit not related to army business or commercial venture
(ice a dog Beene or per®it m bait leaves etc.)said person is NW required to complete dust affidavit
The Office of Investigations would h1w to thank you in advance for your cooperation and should you have any gnadom,.
please do ant haitslaio give as a all
The Deparneeses address,tckpbome and As comber
The Commonwealth of Massachusetts
DepaztmeW of Industrial Mademts
OI a of Investigation
600 washmgton Street
BeiW4 MA 0211 t
Tel. #617-7274900 ext 406 or 1477-MASSAFE
Fax#617-727-7749
Revised 5-2"5 W-WWM gy,gov/din
CITY OF SALEM, MASSACHUSETTS
9 ,
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildine Det)artment
Debris Dismal 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.
I The debris will bbe�disposed of in:
Abg-74!!SiDa C✓*"r)Nb (Location of 'lity)
ignature I4f Applicant
)ZAl ��-
Date