101 MARLBOROUGH RD - BUILDING INSPECTION fI�g61M16iT�EfI A94AD APPROVED BY TW
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CITY OF_SALEM
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BUILOQIQ PERMIT APPLICATION FORD
Permtt to:
(Circle which~apply) Roof. It idl�rt4�onetrtaot Deck SIMd. Pool.
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PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCEBOINQ
TO THE INSPECTOR OF BUILDING&
The fora to bWW to the
urtdereiprwd hereby appYes gamut aooadir►p bllowir►p
Ownses Name �a �" r `Aoh
Ad*m & Phone I U I PM 7ys- �9SD
Architects Name
Address& Phone f 1
Mechanics Name �H
Address6Phone ys G7fzcrAlcon!5DSf 0 ei s74-5--7lolo
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X Ste. of Applicant
SWWD UNDBR THE PENALTY
OF PELRARY
DESCRIPTION OF WORK TO BE DONE
In � fC,1/ U/tiVI S, 4,14
MA L PERMIT T of
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No. --oF Z,
APPLICATION FOR
PIMA I TO
LOCATION
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PERMIT GRANTED
APPFIOVIED
rPFMOR OF
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/organization/Individual): /
Address: ?7�/� 0712 EEC S-
City/State/Zip: Lt)0jW Es t El2 Phone#: 4 7,F— 5679—57
Are you an employer? Check the appropriate bog: Type of project(required):
1.® I am a employer with- 1(') 4. ❑ I am a general contractor and I 6
❑New construction
employees (full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner-,.
listed on the attached sheet t 7• ® Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in an aci workers' comp. insurance
Y capacity. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its -
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL i l.❑ 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' 13.0 Other
comp.insurance required.]
'Any applicant that checks box N 1 must also fill out the section below showing their workers'compensetion policy infommtion:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck
tContrsctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
information. / n
Insurance Company Name: N //T7 l Al
Policy#or Self-ins.Lic.#: 10 CO Cf 4 Expiration Date: 7
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure 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
:)f 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 DIA for insurance coverage verification.
l do hereby certify under th �naftm ofperjury that the information provided above is true and correct
Signature: Date:
'hone#: Q 7S-- 5&9� 5_7(�(�
Ojftcial use only. Do not write in this area,to be completed by city or town offmial.
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#:
CITY OR SALKMv Mw sswcllussn s
PURUC PROPERTY DEPARTMENT
"a WASNINWMMI STSSST. 3ND RLoow
SALSM. MASSACNUSSTTS O187o
TtLS.NONs: 076749-99Ss WM. 380
FAX: 578-740.8848
Sa1Cn!Buis f1/ILns�hw���
Debris DkpwW Form
In accordance with the provisions of MGL c40 3 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, 3150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of Applicant
Date