MASON ST - BUILDING INSPECTION CrrY OF SALEM
PUBLIC PROPRERTY -
DEPARTNIENT
t!C 7.%g Car.Q aistse•iu:a.t4Avc�:u.ups s
11n:YOr7aY/9hi �flit 9i7eJgleN
Construction Debris Disposst Affidavit
(requ►retl toe an demoudon and saw%ation work)
hv=onhm@ with the sixth edition of the Sets Building Cod%7SO CNIR section 111.S
Debri%lid the provisions of MCL a 40.S SM.
9uildinS Permit s _ is isnhed with the condition dint the debris rettuldng item
this wort shall be disposed of in a properly licensed waste disposal facility as dented by%lGL a
tl1.! 15"
The debris will be transported bY:
,e, C, P
rho debris will be disposed of in :
(,aaaw of rkliity)
,.J.usa..,i Cx:L1y)
14
CITY OF SALEM
PUBLIC PROPRERTY
�>~ DEPARTMENT
nt�rarafF.Y Ultlrt:tNl
)&%Yea 12C WA-QiLM:TCNS Rtzr a SAtlrK W.%gLW a.O'1'tsO1970
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Wurken' Compeasadon Insurance Atlldevit: Builders!Contractors/Electricians/Plumben
aDnllcant Information Please Print Legibly
VamelUusirtesslOryaotiratioNlrultvultnll:-Stzlzh �✓/kLP l �il�✓�
City/SMtVzip: lSS f ` Phone P i&
Are you an employer?Cheek the appropriate boa: •hype of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a gent,raj contractor and 1 6, New construction
(full and/or part-tine).• have hired the sub-contractors
2/ \ 1 am a sole proprietor or partner- listed on the attached sheet t 7.)E[Reutodeling
TTTTCCCC ship and have no employcat These sub conasetma have S. Demolition
working for me in any capacity. workers'comp. insurance
f No workers•comp. insurance 5. ❑ We are a corporation and its 9' ❑ Bwldtng addition
nquiredJ officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 at a homeowner doing all work right of exemption per MGL I I.Q plumbing repairs or additions
nnyscIL(No workers'comp. c. 152.044),and we have no 12.0 Ruofrcpaint
insurance required.) t employees.(1\o workers' 13.❑Other
comp, insurance requirtxl.]
•.toy apphCaal Tst checks bee el Most also till out am recline tralaW AMina chair wakae'CuMpoh akm Dulwy ia6wslWi"
'11u wlnn who tubTit this ottldove iadiratbre very are chin as work told than him ewtide eaunnswa Two submit a maw arndsvd Wdiatina r h,
:C.wtrstun thao theft the Iwo Tut adxhad wt addtoipral dwst Mwiry the ram of dw sub4ourasm and their wurke s'osp.policy utrormarim
l uAr tin earpfoyer that is providing warkers'compenradan Insurance for my employees, Below is the panty and Job slh
injarurafka
Insurance Company Name:
volicy 4 or Sclf-ins. Lie. N: _ .. Expiration Date: _
Job Site Address: CitytSlawzip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number an cxpiratlun dat�
Pat lure to suture coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.300.00 and/or one-year imprisomncnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
.if up to S250.00 a Jay against the violator. Ile advised that a copy,of this slatcment may be forwarded to the 011ice of
Im.,ngauutu of rite DIA for insurance coverage vcrificatiun.
/Ja herebyen�y lid, e pains uad enuUie rJary that the hileforadon provided abo is tru sad correct
tii•:utntr' Dj t
t7
Official aye aaly. /b war writ,in rhis area,to lot caap/eretd by city or/own of el"i
City or 'town: Permit/1.Ieease M
Issuing Aulhurity (circle one)-
1. Iloard of llcalth 2. Building Department 3. City/Conn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C.nuact Pcrsmr: _ Phone p:
Information and Instructions
,%lassachuscus General Laws chapter 132 requires all employers to provide workers' compensation for their employees.
pursuant to this statute.an ewPl0sid is defined as""'every person in the service of another under any contract of him
aapress or implied,oral or written."
An erellpileJee is defined as"ail W&vIdt"paemasb4k araoeuaoa.eorporatioa or other legal entity,or any two Or Moro
of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.or the
association ct other legal entity.employing employees. However the
receiver of trustee g a individual,of morshu s and who resides therein.at the occupant of the
owner of a dwelling hoofs having not more eons them apartments or re work on such dwelling house
g
dwelling house of another who employs Persons.to do maintenance.cewstruttiaa deemed to 6e an employer."
or on the mads or building appurtenant thereto shall not because of such employment
be hiGt chapter 132. ¢25C(6)also strifes rose"wary stab or heal Iteeaslag agency shag
withheld the►eauaaee Or
renewal of s uccese or pertalt to operate a business or to construct buildings Its the cemmoaweslth ler say
eppgeaM who has am prodidence of comPUAR"with the insurance coverage required."
Additionally.MGL chapter 152.$23CM states
the commonwealth not any of its political subdivisions shell
need acceptable ev
he performance of public work until acceptable evidence of compliance with the insurance
intern say coeinact for t
requirements of ibis chapter have been presented to the contracting authority.-
Applicants
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation a if
necessary,supply sub-eontractods)name(s).addren(es)and phone nurnber(s)along with their certificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or piers,are not required to carry workers'compeosstisa insurance. If an LLC or LLP does have
employees.a policy is require& at advised thin this airW vit may be submitted to the Depermnent of Industrial
Accidents for confirmation of insurance coverage' Alto be sure to sign and date the affidavis. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,ant the Department of
Industrial Aceidoau. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,pleafe tall the Depamment at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Olficiab
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.
t'leasc be sure to lilt in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob Site Address"the applicant should write"all locations 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
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new 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 i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhe OI hide of Investi`o'anons Would Itke to thank you in advance fur your cooperation and should you have any questions.
plcuse du not hesitate to give us•a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oak*of Investigation
600 Washington Street
Bostoar MA 02111
Tel. #617-727.4900 ext 406 or 1-977-MASWE
Fax 0 617-727-7749
2cvi,cd 3-26-03 www.niaw.gov/din
Cl I Y =VILL
r PUBLIC PROPERTY
DEPARTm&NT
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A_pPLICATION FOR TSZ RF MM RZNOVATION snNrr>Q>rrrrrnllT-
DE_HOLITION.OR CRANG9 OF USE OR OCCUPANcy, FOR Arty EXISTING
STRUCPURK OR BUILDING
1.0 mm INFORMATION
Locedon Nama: 8uikllr
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3 fv10!S6", S .
Properly Ie loeabd In c Carwallon Ann YM Hkft t 0WM YM Al
2.0 OWNERSHIP INFORMATION
2.1 Ownw of La" _
Nartw. '
re-
Addrem /"[
Tele~..
3A CONPL6Tt THIS SECTION FOR WORK IN EYIa?1M 9UILMNGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use 3. New
Demolition
Approximate year of Area per floor(st) Renovated
construction or renovation
of existing building New
Md Description of Proposed Work:
0
'� E�+ S'C .� a(e
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Navin (0 S tom{ to cl; a lol wc�� 2r,a1
P
�6at S
Gee van GeZ, Qld ahe
--- — ---Mail Permit to: n u r k (a O
What is the aurrent use of ow SuddhV?
? it dwelirq,how many unila?�T
Materiel of BuiWkq Ai/1
yya Mts�Ydtn f Cantwa to LaMlt Lf-_ ?
Araltitads Name "
Addreaa and Phoiw
MedwWs Name i
Address and Phone is 2_2.
Canetrtcdo^ SUpWviaaslleenssS e'SovFl99 HICRepistrsthn
Estlrnatsd Cost of Project �' -�6 �Fei CalwNtlon
Eatlmated Cod X f71$1000 Residential
Permit Fee f
-- - - - EsOnated Cast X f411111000 CanrnerdaL--- -An AddNlonsl fdAO Is added as an
Administrative dw9m.
Make Ore that all fields am properly and Ispiby written to avoid delays In proceselnp.
The unasmipned dose twreby apply for a Bubdnp Permit to bulid to the above
sp@dkgWm Signed under penalty of psrkay t
Date
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