38 MARCH ST - BUILDING INSPECTION (3) e
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VWR TO A.1><N W BOO GRAWb
CITY OF SALEM
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PLEABE PEZ 01R LEBmY a cam us y TO AMOn m A"N PROCfI w-g
TO THE l"8PECTOR OF BUILDINGS:The '.
hweby appim for a po mk to bukd a000rdklo ft.ldlorrYip
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AMhMWS Name �U /
A*ftn a Phone N -
Madnr Name 1>G
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APPLICATION FOR
PEirfT TO
LOCATION 3
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INSPECTOR OF OLWJDt Qs
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"eParrnaenr o%Jnousnru ACGaenta
OWN Oflnwidge&XI
6M Waskinatom Shaer
Boston,AM 02111
wwsnsrassSnrtJslta
Workers'Compenaadon Insurance AfNavk: BuMerLConmctors/Elecbidam/Plambers
AnullcaM Infa madom place Erbil Lestilrly
Name mmwmoovmizwdowmmvi&@W
Address: (4Z
CityMne(Z* / 1ho 9-9-0 g22
Are you u empl W CYak tWVprWfxW boas
1.131 am a employer wily 4. ❑ 1 am a Seaeral eonvaclar ad 1 TYPO dProl*ft"4dred):
empbYM(IA md/or part-time}a have hired me & ❑New ooao rvedon
2.01 an a sole pmpriebr or primer- Hoed on the suarhed sheet t 7. ❑ Remodeling
a*and have an employees These bm tt. [] Demolidn
waking fbr me is say capacily. wodw,coaw.issuance. 9. Baildtog addition
[No worker'oomp.toarom 3. ❑ We area aorparatim add ib
re I ; P ') oflWW have exercised their 10.Q Ebcww mpaks or additions
3.❑ I am a bow wndr doing an work rig%ofc=Wd s per Mt3, 11.0 —19W or additions
myeelf(No wakens' comp, o. 132,)1(41 and we have no 12 f rapaiis
m ]t awbyecL Pb wotkm• 13.❑Odra
CmP.iaaaanee requital
;Any APPUcW dace 4ecb bone at now oleo®am ar medoa bebw dtowml drtr wmbee'
Ho mowms who mbmk No atadnk kWkmdml stay m domes as wvok ad dm tme aaMda aoumedm nwd subuk a mw offiyn*eCon&wk n dmd ebeab Bola tau mt dbebed m eadk and abed dwwbtl dr mow of dr m6vambae'bn god dt$vmdm-000p vdorn01
f�rAtdr L>proNGllitB worAvra'eotypewstalot brr+rrr+aee jw ay ea;loyera. Below b dks
Pal twllo8 sAsr
Iasmaaa ConVasyName:
Policy N or Self-ins Lic N _- 2 �i�®� 5/ 1 Expiration Dace G
Job Sim Address:_ / Ott GitYmtatdlip:
Attach a copy of the workers'eoanpeasatloa poaey deehvation page(sY"he the policy number sad cgdratlou date}
Failme to Wc=coverage as required under Section 23A of MGL a 132 can had to the imposition of ai®al penalties of a
fore up to$1,300:00 and/or oaayew imprisonment,as well as civil pmahies in the fbrm of a STOP WORK ORDER and a f m
of up so$230 00 a day against the violasa. Be advisod that a copy of thb sudemmt may be furwaaded to de Of5ce of
Investipdoos of the DU for h avace covemp verifkados.
I As Aiaryesrsgy p6st tadtprathle rAe lnfdraurlaaOrwlld tbtw aar nut
- 5
Off&Ad use oalp. Di xa wrfie!n&k Br et,tt br eompLV8d bl eAy M town o,Q&fa(
Cky or Tower: Parmk/t loesbe 0
fusing Autborky(tirde one):
L Bosrd of Heakk 2.Building Department 3.Cltyfrown Clerk 4.Electrical Iaapeetor S.Plumbing Inspector
6.Odwr
contact Pausm Phone#.
to 152 require A MVIOYCU 10 paovxle warkaa' tee uwu ,,— bb%
Massachusetts Geoa Laws chap y defined es"•••way pawn in the savioe of another undo any s`^["f�'
Pursuant 10 thin stuou, an ewpbyeee
ass or mrphed,oral oar WO'e'-
- en
d
;coapesatioa r odta kpl entity,Or any two or mow
An eerp/nyp defined as"ats md+vidwl,parmashrp, kYl es of a deceased employer,or INS
> in a joint tnlaPl
of he owing t itR of adw 1ep1 estnY*tupk
e ofs divd P atto wo asides Wxh air hPel noYaaafs Iio of**
aeiva ar 1taAmSpartunmrs n ves the
boom
ft
° ho w of another�1�pawn do mamanaodwCaingboaWa+a a .toobbe to 1oYa»
ar an the founds orbmldiag thereto sban not becstse of each aapbY�
MGL duw 152,12SC(6)40 SUM that"evf date or beat seesdsg t etWi shd be wkrbaM the htwaoee ar
rawwO at•lieSM or P�to operate a bedsess v to Cam
ttomlly,MGi.dtsiptasPredatedisemen
u "N� wift the Warsaw COWIIIII Mild"
Coa 1&nor mY of its poleial wDdi� abaD
ffi the pafa=ma ofpoblie wo*tm41 aoMuble evidence of cost lenoe wib the inaurasce
eels into any contact requiremmu to
bavebeea Pied to SS eott�tr C*9 authM*
of this chap
AppBt&ub the bona that apply 10 yaw ttratstim�'if
Pkeee fill out the woalcen aflldsvit completely.M cbednoi
newaay,arply s sb addran(ca)end pbou �m Via) tins the
woe Limited Liablft ComPi1»(LLQ°a Limited pees t i n impet our(LLP)
nxub s or parf° to carry worked c av tm,ybn
mtwraooe. Nan LLC ar LLP does hsvo
emP>0y�•a P°�' �'h°d ad�Be advised that thin aeaanvlt maY>+e 1D the affidaDWT IL °t Indidxvil
Aocidams for coto&msnon of imutmce w aape. Aim be we to dp sad date the atlldavit. The atffidsvlt aboald
be returned to the city or town mat application for me Per'> � $ re4uCIM4 so>pes obtain a DVOWWO of
lttial Should you have any 4om ,
self m�lt�upom�a� �mmba hated bebw: SeK ioataed complete tthoald aura their
C"of Tows OBidals a space at Ibe bottom
>s oampkte and printed k&IY- The Deptrrl WW bss Prwlded 1oMv
Please be farce that the affidavit has to contact You revnding the OPP
of the affidavit for YO11 to out in the wart the Ogee of brvestiptions be ad&Mn,an 8PP>�
please be eve m ffi in the paw now which wr71 be used id a reference maths.
Ucaoic m in any given yew,need only submit one affidavit mdicatmB torrent
that mina submit=*W Pam�1C�"�Site AddreW the appheant shaild write"all iocatiom in (ci1Y v
policy mforasdon(if necsasy) the city of town may be Pt'�to the
low }}»A dopy of the aflldsvit that hen bees o�ciafiY ttttmrped A new affidavit molt be filled out each
applieaes s proof that a valid affidavit is as fife for fhaae pamm no<Mated to any Weinees Of
OD
yes.Whore a home owaa q cith s is obtai ft a liaose t permit p this affidavit
(i.e. a do`liceut at perm*to bon kays ex.)said pawn
IkIld
would lute 10 thank you in advance far you aoperation and amid you ben any gaatioas,
The Office of betb i o give
us a call.
pkase do Intheattate
The DeparuncaVs address,telepboue and In numbs
The Catmmonwealth of Massachusetts
Deparmlent of Industrial Accidents
Ofta a of Investtoations
600 Washington Sued
Boston,MA 02111
TeL # 617-7274900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Rwised 5-26.05 WWWM=.gov/dia
R CITY OP SALiMV d1ASSACMUSZWS
PUaLIC PROPERTY DEPARTMENT
120 VAwm unarm Gruff. 3II0 PUMM
Im ms MAOIa70
TEL (0761749-06" Ern. 300
PAR (670)74&""
STANL9V A U@ ICl. JIL
MAYOR
DISPOSAL OF Dt3 N AMUVff
Is a000dsm WA 60 pro iaio w atum a Iq 041 ackemAWV due a,a coadttioa
of sdwbs PW=k r .as ditb=U t g dos Ida=W*Uodm aatvdy
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AFULLY2nowing
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Naas of Applidaal
Fins Nama�itaay
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or macoln be digmW is a popaly-tiaeoaad solid.watt di"W
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I blaldfop permits or ticmadr are r
mdkata t5r loeaQoa ottha 19idliq.