108 MARGIN ST - BUILDING INSPECTION What is Ute Glrrent►�d the ? how� ?
Materiald Buis&*? C�o— �—
wV1 �y��Cordbrrrt b Lauri
Afd*sa$Nana
Address and PhOM
Medted'e NaM
address and Phone HiC Replabldw a,ejuc
On SLWWvjaM License a
Esthnalyd Cost of Proled o 0 0 Pame F«Cala+latlon
Es*naod Coat X$71$1000 Redder"
Parma F«i
EstYnatad Coat X=41I:1000 Camnarela4 —--An AddNkMM 1&00 is added as an
Admk*waove durpe.
Make sure that am
flalda are ProPsrV and legibly wrmen to avoid delays in Procadt+0-
The xW.Wed does hereby W* •�� ParmN to build to the above stated
aPaallgtl m Sipmd under Pa WV of Padury
Date 10
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soars or estiamg tiegw.uons aaa snaa.ras e' f'
k, Lit fE of rigieinNon valid for individhl use only l
HOME IMF9f;OV6MENT CONTRACTOR before thi Ekc "tion date. 1f found Minim to: i
t 144630 : Board of BdBding Regulations and'Staiittards
P f128f2008 One Ashbaitoi Place M 1301
H - fiyge OBF L- Boston,Ms.61108
l31Ci'SLOCK CON
UG1ON }} 1
GARRETT SHEA
t0 PEARL ST "t, ✓'F Ti ;, yte .,,i- --er�NJ�[li+ii j�' r rr
SALEM,MA 0976 q
i ... � Administrstor Not vaNd withodt signature !
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\�411T'at F.Y Uart:lxl
M\YOa l2C 11/ASfa4.Y�tSratsr•SA
t•u.htASAt.'I n aa7'IX 0197Z
f►r 971.74-1,"" •FAX:97L740.9846
Workers' Compensation Insurance Affidavit: BuilderstContractors/Electricians/Plumbers
Applicant In o t)oPlease Print Letitity
Name Ilruvft-WOrtanirationtlmLviaAml): XJ L
Addrm: b re",r'I
City/Stawzip: Sn 1,e 4 nn Phone q:
Are you an employer:Cheek the appropriate bore
1. i am a e 4. 1 am a ry of project(required)'
❑ employer with ❑ general coelraetot and 1 6, ❑New construction
employees(full sntYer p wtinu).• have hired the sub cuturacton
2.rm I am a sole proprietor or partner, listed on the attached sheet 7. ❑ Remodeling
ship and have no employees Theca sib-wnpsetas haw g. ❑ Demolition
working for me in any capacity. workers'comp, insurance. q, ❑ g�di�addition
,No workers'comp. insurance 5. ❑ We are a corporation and its
requirnx.J officers have exercised their lo•❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repair&
insurance required.) r employees.(No workers' 13.❑Other
comp, insurantz required.]
Any Vplicwd this c►cdn ben el moo also n'Wt rut am secbao bclow dtowiee'hilk nvstoW eumpandhw Policy iailtuu iiep
I I.,nw,w w►o submit"aftldwit iadieatbg nny am Jain%all weA and eta him owake cammemm nswsl aYMni1 a nave amtdaail indiaaina uu►.
�Connaama n►a climb eke ba mutt anaelad a addilimw What.bowing dw naaw Orem mtd their wuri a i,oww.policy mfbnnu w,
/am an map/oyer that Is providing workers'coarpelawdon hisurance for fay erap/oydrt B�/owls the poHay and Job sib
h1form?"I L 1�
Insurance Company Name: Vl9 \ \,
Policy Y or Sol(-ins. Lic. 0: - pirdts ate: r(
Job Site Address: l(� — CilyistatuZip: �Le2 MLT
A mach a copy of the workers'compensation pt Ile declaration page(sbowing the policy number and expiration date).
Patlun;w Wcure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition oreriminal penalties ttf a
Fin,: up to S l,5()0.00 and/or one-year im isomncnt as w•cll as civi M I pcnaltiar in the form o(a STOP WORK ORDER and a fine
orup to S250.00 a Jay aguinsi the violator. He advitcd that a copy of this slawment maybe fu y rwarded no the U17ice of
i. Inr.,hgau�ttu of Qtc DIA for imurat:cc atvcr •arc ecrificatiun.
/ /o hereby den/jy un the pains and penaltes of perjury that the hifermarba provided above is true and correct.
tiiaaan�ra
Pfs ire p:
U/J/a•/rd ore&ft4t A0 ea write/a the area,to he completed by rRy or town ojp-lid
City or '(own: _. Permit/Lleense M
Issuing Aunhurily (circle one): _-
1. Ituard of ivaith, 2. nuilding Department 3. Cityfroon Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cuulact Pcrson: _ . . _ _ __ Phone p•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers ovi theservice another Under any orkers' compensatios for thick Ct of wYCM,
nk
pursuant to this statute,an etwpfeyee is defined as"...every person
e%press or implied.Oral or written."
atsodaM&Corporation ter other legal amity,ter any two or more
Au errpfejw is defined as"tin individttal.patttanhtP. to er,or the
of the foregoing engaged in a joint enterprise,and incltpfiftg the legal representatives of a decmplo cmD Y
�saoeiatiou or other legal catity,omPloyulg employes However the
receiver or«turns of an individual,parmetahtP. end who resides therein.air the occuperrt of the
owner of a dwelling house bho a not none roan three maintenals or re work oa such dwelling house
b dwe"irtg bouse otanotlter who employs persons m Ole tttainteoance,cunstrucaon dt to be an employ"•"_ _
or on the grounds or building appurtenant thereto shall mt because of strati employment
be hiGL chapter 152.425CM also states dmt..way state or beat Iteetsshg agency stag Is the eithhold the Issomisca Or
oaweaW erf say
renewal of a Ikesse or permit to operate a busMO or to eotsatrtset with the bd��lnsuraau coverage required."
appiticN who bee ant produced acceptable evideaea o[eooptlooe
AddtCtcaioally,MGL chapter 152.42SC(7)states"Neither the comunmtwealth nor any of its political subdivisions shell
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 audrority-'
Applieanq
on afildavit completely.by checking the boxes that apply to your situation and.if
Please rill out the workers' compensation horn number(s)along wilt their certificate(+)of
necessary,supply subconautor(s)name(+),address(es)and P LLP with no employees other than the
insurimm Limited Liability Companies(LLQ or Limited Liability Partnerships( ) Ploy
ars net required to carry workers compensation insurance. If an LLC or LLP does have
members or partners,
employees,a policy is required. Be advised that dtia affidavit maybe submitted to the Department h affidavit
industrial
Accidents for confirmation of insurance coverage- Also M sure to sign end dote re affidavit. the affidavit should
be returned to the city or town that the application for the permit or license f being requested.not the you am required to obtain caper kcM* of
Industrial Accidents. Should you have any questions
compensation policy.Pleaae Call the Departmentat the number listed below. Self-insured companies scout eater their
self.insurance license number on toe appropriate 11IIC.
City or Town Oflicisb
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•
1'leasc be sure to till in the parmiLtlicense number which will be used as a reference number. In'addition,an applicant
that must submit multiple perm itilicense 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
towns"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 now 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 burn leaves efe.)said person is NOT required to complete this affidavit.
I'he Office of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us u call.
The Department b address. telephone and fax number:
The Commonwealth of Massachusetts
DeputInent of Industrial Accidents
OAIa of Itrvadptlaw
600 Washington Street
Boston, MA 02111
Tel. #617-727.4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
2cvistd 5.26-05 www.nim.gov/dia
CrrY of SALFm
Ada PUBLIC PROPRERTY
DEPART%t l*xr
��c►•� 13t ra.�Itw-:ow S 1[stT•iu:�r,ft�vr.►t a.•Iv:.ar.
Construction Debris Disposal A fidsvit
(required for all demolition and renovation work)
In aceonhmc w ith the sixth edition of the State Building Code 7SO CUR soction 111.3
ocbri&and the provision of M. GL c 40.S S1.
lilt Wol Permit N _ is iswed with the condition that the dcWs res ddng dram
this wortt shall be disposed of in a property licensed waste disposal facility as deRned by 1QGL e
1 l L.3156A.
The debris will be transported by:
name.u'ttaul•d
rho debris will be dispowA of in :
uuneY tY)-
..u,c
- EmroF
ti
PUBLIC PROPERTY
DEPARTMENT
t3Dflsnsar•s„u,.. �c„=o�9'ro
D
311, OR
1.0 OU INFORMAnON
Location Now g I ��
Address------------ - --- --- - - - - -- -____ __ __
PrcpsAy Y Wailed in a: Ana Y _Hwft%011m t
ETa !
w INFORMAnON
LaW
[Ob rtn S�
0�7
sA COMPLETR TMIs SECTION FOR WORK IN 0UB Wp BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New
Demolition Us�g
Approximate year of Area per,floor(at) Renovated
construedon or renovation ?�
of existing building New
a of Description of Proposed Work: �, �� V Up,
--- -- ---Mail Permit to: _► n ,� nn„� " �,� �-- �I o� 4 n Pr