194 MARLBOROUGH RD - BUILDING INSPECTION (2) CITY OF SALEM
4.
- - -PUBLIC PROPRERTY -
- DEPARTMENT
;,tstnr'ntrr mtlLfCvai
%t%yt* 12CVA%&1Q.-YCIS'aZWr&SA1!u X019n
7aL 976-743.95" a F..x:9M740.9s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/PIumbers
Applicant Information Please nrr t Legibly
Name l9uainessfOraaliratiowl"Vidustl: re A V ��,,�s Ins C�nrT.�Tio.
Address: ., r _ e d
cstyiststclzip: Sale r., %- em-" lie a: 9 S- y f 2 z..g o
Are you as employer'Check the appropriate bona F6. 0
roject(required):
L Q 1 am a employer with 4. Q 1 am a gatnxal contractor and 1w conatr equir�employeca(full and/or part-tinu).• have hired the sub-comractora2 ction
I am a sole proprietor or partner. lined on the attached sheet t odeling
ship and have no employers Them wbconn ietors haw olition
working for me in any capacity. workem'comp. insurance. diag addition
[No wm tcrs'comp. inauranee S. Q We am a corporation amp is ding!squired] officers have exercised their ❑ repairs or additions
3.,Q I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.111(4).and we have no 12.0 Roof repair*
insurance required.)r employees [NO workers' 13.Q Other
comp. insurance requireLJ
Alp appkcay the chucks boa at mom also all era are WSIM buluw atowisa rkeir avakto'a ,PM lk,pdiry iofiamW ioq
Ilonaatwnus who submit rain aflldwn indiratina theyate Juiryl aftwwt one MCe hoe OWtfda tenkroetxa saw•ubmu a tww aftidavir imlierina look.
-C'„ttua sm thot that the boa mot aeauhad ar addttlewl awal.towing do time orrM and#how Watkins'cow.polity mfhmtadve.
I tar an atapleyer that Is providing workers'compensadoa Luararrce jot my employers Below is the Polity and job We
_ ,. _.sell ipjarrwurtirrw,
Insurance Company Name:
Policy 4 or Sclr ins. Lic. 0: _ .. Expiration Date:
Job Site Address: citytslrtuzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failuro u)secure coverage as required under Section 25A uf.IGL c. 152 can lead to the imposition of criminal penalties*(a
meting,uPto S1.300-00.anWor one-year.lmprisamnem"is-well as civil penaltii s in file r6a ofa-STOP'WORK ORDER and a fine
of up to S250.00 a day againsl the violator. lie adviscd that a copy urthis statement may be forwarded to the Office of
I n,.,ngauoru ul cttc DIA for insurance coverage vairtcapun.
I din hereby c.nijy r the pa' and penulnes ujperjary that fhe injarfeatioe provided ubaw is rile and correct
F
"l&$Ctfaly, Be nor wrlp/a thh area,ter be raarpleirdby elly of town a fflCh LorTovrn:g Authority (circle one):rdofmaith z. tiuitding Department 3. Citylfown Clerk 4. Electrical Inspector S. Plumbing Inspector
er
11 cantact Person: Phone p:
Information and Instructions
tI useru General Laws chapter 152 requires all employers to provide worked compensation for their employtrM
Mass,ch is defined as'...every person in the service of another under any contract of hire,
suartt to this statute.an enyloyet
express or implied,oral or written.
association.corporation or other kgsa entity.or any two at more
.k n ckVjoyer is deflaed ce"m is vidwti. � resentatives of a deceased employer.or the
Of the forgoing engaged in a joint enterprise,and including the legal rep employing employees. However the
association of other legal entity
receiver or trustee of an iudividusk partaer
stnP. and who sides tbeeeio a the occupant of the
owner of a dwelling house having a not mote than torso maintenance.apartme ds
dwelling house of another who employs persons to do nebecusef each employment
y centre work oo such an cmp!house
or on the grounds or building appurtenant tbeteto shag not btxattaa of such erttploynneot be dewaed to be an employes
biGL chapter 152,625C(6)elm stares that
..every state or local licensing agency shall withheld the issuance or
too rate a business or to construct builMOV in the commonweakk for any
n reewal of a license or permit acceptable evidence of compliance with the Insurance coverage require&-
appilce""be ban ant prod
Additk=lty.MGL chapter 152,$25C(7)states"Neither the commonwealth nor any o[its political with the ins shell
far Performa°ca of public work until acceptable evidence of compliance
with the insurance
enter into any contract authority.-
requirements of this chapter have been presented to the contracting
Applicants
Please fill out the workers'compensation affidavit completely.by checking the boxes than apply rr your situation and if
er
necessary.supply attbconraccor(s)namc(s�address(es)and Phone nutnber(s)along with thew cernifica s) than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employ
ees Olb members of partne re rs,a not required to carry workers'cnmpensattan insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit be s maybe 90 and d to the Department
ent of Industrial
Accidents for confirmation of insurance coverage Alan M sort to$ign and date the aflldd. n The affidavit ntould
be returned to the city or town that the application for the permit or license is being requested. not the Department of
lndustriai Aeeidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation polity.please call the Department at the number listed below. SelRinsured companies should enter their
self-insurance license number on the line•
City or Tows Offlclab
Please be sore that the affidavit is complete and'prmfed`Icgtbty. Ttie'Depatanent has provided space ar,dte. m::�...
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the purmitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pettnit/license 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 locagionx in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
lid affidavit is on file for future permits or licenses. A new affidavit must be filled our each
applicant as proof that a va
or citizen is obtaining a license or permit not related to any business or commercial venture
year. Where a home owner
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
i'he Ot iix of Invcstigattons would like to thank you in advance fur your cooperation and should you have any questions,
please Jo nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
oft*of Igivestipttle"
600 WAS19nQtm Street
Boston,MA 02111
Tel. N 617-727-4900 ext 406 of 1-977-MASSAFE
Fax N 617-727-7749
Rcvi>cd 5-26-05 www.nim.gov/dia
CITY OF SALEM
- PUBLIC-PROP-RERT-Y - - - - -
- - DEPARTMENT
,.%mat all, AMS- A.
aL��• 13C7.�rv::outS 7rST•iuefl,lt�vgt�r.��1s::4
t1tt:rON�b+r91f�f.�t 97sJaptiss
Construcdon Debris Dbposaf Affidavit
(reyuiral for A daatolidon and immadon wart)
In soeo WWM with the sixth edition d the Stet Bundles Code,7SO C11IR section 1113
Debris,wA this provisions a(MCM a 40a S 541
SWARI fft"* _ _ is issued with this condition that the debris resuidns f m
this wort shalt be disposed of in a property licensed waste disposd facility as defined by%IGL.a
111.S l"A.
The debris will be transported by:
I++ome o[Hnulal
rho&-bds will be disposed of in :
G+:un+r uY rx+trt )
Y
Swiaw,p t�
{
' :AR
aPPDTME►�rr
Magnavox NI"
�:ma+s.ssss•R�m�agw
APPLICATION FOR THE REPAnL RENOVATION LUL33M
DE.KOLI T &OR CHANGE Of USE OR OCCUPANCy, Irog ♦Ny MStr> G
STRUCTURE OR BW.DIIITQ
1.0 WM INFORMATION
Location Now
---- Property Addretc --- - - - - --- - - --
thoprrty Is beabd In a;Corwrvskm Am Y#4 HYfoito okMd YM 41
F
HIP INFORMATION
rLand ,I-
Telephone: ?--I q s- 41 3S
3ACOMPLEU THIS SECTION FOR WORK IN E7U2M NG fpJILDINOS ONLY
Addition Existing
Renovation Number of 3torkte Renovated
ri
ange In Use New
moGtlon Existing
roximate year of �A` Arsa per floor(eQ Renovated
struction or renovation /$90
of existing building New
add Description of Proposed Work: .V, 3.T/a//
Cprne In S� d e enTr�7
--- -- ---Mail Permit to
„feaweguildit?
What Is the cuff” //�.0 It dwalin&now MM wft?—--
Maarat a e�,iwkw?
we to euMV Conft .to Law? --j e-s Asbestos?Archamas Name
Addrom and Phow
j0 ms&m es Name 4 4 c � / eVo r
Addr«s and Pno,,.
Coestrucftn suPsmism Liew"O 0 HIC Raps mftn 0
Eswnabd CaR a�Prajnsa�t o too, �' palm F«Cabal m
Eslknaosd Cost X$7/$1000 Rasidentlat
EsWndmd Cost X s41/111000 Cam weld
- An Additlona0 S.QO to added «an
Adminbmovo dwg&
Make sun that ap flelda are properly and Isow wrUtan to avold dNrya In Proepsinp.
The undenlpnsd do"Eby ap*for a Build ft Pam*to build to the abow stated
spacr4sdm,s. Sipnad under panaMy a p"p"j'
� I
N � �
A