36 MARCH ST - BUILDING INSPECTION ft�1+611tlsi�Ef ND A"ROVGD BY TWE
ImBRIGM P6WR TDA PRJV#T AEWO GRANTED
CITY OF_SALEM
No. S -D or.
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BUILD" PBRWT APPLICATION FM-
Pam►a to:
(Cko*whiohewr apply) In" SWW4 Comtniot Dank. Shad, Pool
OMW.
PLEASE RLL OuJT LEGIBLY i COMPLETELY TO AVOID DBLAYB W PROCEBSWG
TO THE INSPECTOR OF BtJILDINOS:
The wwlsraiprwd hereby applies for a permit to bWW ao wft to the fo MM
Owners Name i�N
Address 6 Phone Sr.
Ard*ed's Nam
Address A Phone
Mechanics Name 90Wf6 6n X4W rt nr� -
/ -
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whet Is the prpow at b? �L F/firHit —, DwEat/iti-
d buYdMlp? L✓co o/i M a*No&*,for how mmy mwAn?T�-
wr WkbV oorram to law? y jf-t Mbwos?
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BMW IAd =THE PENALTY
OF PSWURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: /67 Syron/ lr414h PW of g 7 a
1
No.
APPLICATION FOR
PERIRT TO
f,7�q
LOCATION
3C MaReK PERMIT GRANTED
GRANTED
PECTOR OF SALDIM
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
ye 120 WASHINGTON STREET, 3RD FLOOR
aMINB SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
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:
l7//u �f lJvr+�P5rE2 (Location of Facility) t7M4 1"74
.
6Lie -z
Signature of Applicant
//ll7 /d.7
Date
The Commonwealth ofmassaettasens
Department of Indus&W Accidents
O,, ceofInvestigadons
600 Washington Street
Boston,MA OZlll
wwKnumsoddhs
Workers'Compensation insurance Affidavit: Builders/Contractors/ElectridansMumbers
please Print Legibly a eei Iy
Avy—Hcand 1110111
Name '—
Address:
Ci /State%Zip• 7A L �', ,h A y, z 7U Phone
• er?Cheek the appropriate box: Typed project(required):
Are you am employ q. 0 I am a 9MW contracOr and I 6. ON eouffne ion
1.❑ I am a employer with • have hued the nab oonuacbn
loyeea(Sill and/or part4ftw). 7. Remodeling
� listed on the attached sheet=
2.IL!1 ► am a sole pmpnemr or Parma- .Phew sub-eoatracaom have 8. ❑ Demolition
ship and have no enVIOYeea workew comp,ioswance. 9. ❑ Building addition
working Son me in any capacity. S. 0 We are a corporation said its • or additions
(No worker' comp.insurance officers ban exercised their 10.0 Electrical npsiea
right of exemption per MGL 11.0 Plumbing repairs or additions
3.0 I�homeowner doing all work
.. c: 152,11(4),and we have>b 12.0 Roof repair
myself: (No workeis emnP• iNo wotkas'
d.]t employees. 13.0 Other
insurance require
comp.insurance tequired.j.
the scum be
;Any eppHcam that drab box M1Haut aLo 6a-nut an wait and torn bi a �qn=0 submit!new affi&vit ion amb.
?Homeownaa woo anlxoit this davit i moY dome
tCoobWM dw check this box moat atteehed an additional sheet showing the none of the aobcmhutaa and dish wodM eenq.potiry mformsdoo.
am an ewploya tkat&provWled workers'ceoWnsadon lnmmwe jor my employees Blow o toe poag and job s le
lnfor
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Data:
Job Site Address: City/StattlLip:
Attach a Copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as dune user Section 25A of MGL c. 1 52 can lead fo e o�TOP W� penalties sf�
fine up to$1,500.00 and/or one-Year iaglrisomnen;as wen zd civil penalties
of up to$250.00 a day against the viohttor. Be advised drat a copy of this statement may be forwarded to the Office of
Investigations of the DIA for imagrance coverage verification.
I do kenby cerdjj sndsr tkeptrbu and penabies ojpe1hr►Y tAtat tba information pwikd above b tree and confess
�-z •,cL�e Date• // /�/v�
#, -74- ) S- 6
o,Blew use a* Do nit wrAw in thin ana,to be eoarplsld by A&ormwn oaleld
City or Tows: Permit/Ueense M
Issuing Authority(circle one):
1.Board of Health 2.Building Departmest 3.Ckyfrows Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
ro
1111Va annaaaA%FAA Kul%& ianAa.l laT6.a.aVa,lQ7
Massachusetts General Laws chapter 152 requires all employees to provide workers' compensation for the'¢employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or bphed,oral or written.»
An empbjw a defined as"an individual,parmersbtp,assoaauon,corporation of other legal entity,or any two or lame
of the foregoing engaged in a joint cuterprisq ad including the legal representatives of a deceased employer,or the
receiver or.trs rm of an individual,partnership,association or other legal entity,employing employees However the
owner of a dwelling house having not mom than three 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 aplartenant 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 agesey shag withhold the hsuanee or
renewal of a license our permit to operate a business or to construct buildings In the c:ommosweandt for Busy
appikaut who has sat produced acceptable evidnce of eompilasce with the b»uruee coverage required.»
Additionally,MGL chapter 152,125C(7)states"Neither die commonwealth nor any of its political subdivision dun
enter into any contract for the performance of public wotk until acceptable evidence of compliance wig the isstrrasce
requirements of this chapter have been presented b die couacting authority»
Applicants
Pkase fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub•contracBm(s)name(sl address(es)and phone nnmber(s)along with their certificate(s)of
iostranca 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 requnr3 Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Abe be sure to sign and date the&MduvL The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Awxlea.,. Should you have any questions regarding the law or if you are required an obtain a workers'
compensation policy,please call the Department at the number listed below. Self inspred companies should eater their
self-insurance license munber on the appropriate line
City or Town Officials
Please be an that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to bill out in the went the Office of Investigations has to contact you regarding the applicant.
Please be we to fill in the parniNticense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrittlicense applications many 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 (coy or
town)."A copy of the affidavit that has been officWIY stamped or,nolied by the city or town may be provided to the
applicant as proof that a valid afWavit is on file for future permits or licenses. A new affidavit must be frilled out each
year.where a borne owner or citizen is obtaining a license or permit not related In any business or commercial ve ntun
(ie. a dog license or permit to bu in leaves etc.)said pe wn a NOT required to complew this affidavit
The Office of Investigation;would bite to tank you in advance for your cooperation and should you have any quesdona,
please do not besitali lb give us-2 al
The Department's address,telephone and fens nuasber
The Commonwealth of Massachusetts t
Department of Industrial Accidents ,
Office of Invesdgatiow
600 Washington Street
Boston, MA 02111
TeL #617-7274900 ext 4o6 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26 OS www.mass.gov/dia