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MAIL POW
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APPLICATION FOR
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The Commonwealth of Massachusetts
Department of Industrial Accidents
QQce ofInvestigations
600 Washington Street
Boston,MA 02111
www.massgov/dla
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electiricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiorpnizationthtdividoo: /���YI! Y/ Con o i Z/xL -:Tne
,
Address: ,-2s OfOGA 5AS�
City/State/Zip: Sale ✓l Phone#
Are you an employer?Cheek thi-ipproprlate box.' 'Type ofproject(required):
1.R1 I am a employer wiih 4. 0 I am s general contractor and I 6. ❑New construction
employees(fan and/or part-time).* have hired the soli-wutractors
2.[3 I am a sole proprietor or partner- listed on the attached sheet. i 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working;for me in any,capacity. worker;$' comp. insurance. 9. E,Building addition
[No workers' comp,insurance . 5. ❑ We are a corporation and its'
required]-.! {a, officers have exeIrclsed their 10.0 Electrical repairs or additions
3.❑ I am a homeowner.domg all work right ofckemption per MGL' 11.0 Plumbing repairs or additions
myself. [No workers'.comp. c. 152,§1(4Y,and we ha4iio 12.❑ Roofrepaus
insurance required]t. employees. [No workers'
comp.insurance r6 e& 13.E Other
•Any applicant that checks box al must also fill out the section below showing*air w?rtm,oornpen�tion DuficY mfimmtion .
t Homeowners who submit thi'affrdavit indicating they-are doing all wort and than Z oataide cap[mxms mitet sutsrdt a new affidavit indicating such
tContrac ors that check this boinuse attached an additional sheet showing the nmrre ofthe sub-contactors end thm workers'comp policy bBanrretion.
I am ari employer that it providing workers'compensatlon Msruweee for my empkyeir: Below 1i the po&7 and job site
Information L rJ4� ��G��
Insurance Compaq Name: �/7 /a
Policy#or Self-ins.Lic. #: Expiration Date: 9- 7 0
Iob sinAaatesa: gJASO/l S City/staterzip: Sql e,A yr/A. 6100
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
of 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.
1 do hereby certify ands 0 pains and penalties ofperfury that Me informadon provldtd above b true and correct
Si true: D : of16
Phone#: 7 - 7 5'76 .
Offleld use only. Do not write in thin area,to be eompkied by cby.oi town ojJlc&j
City or Town: Perms Jam#
Issuing Authority(drde one):
1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association'corporation or other legal entity,or any two or more
of the foregoing engaged m a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employee& However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the`'
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building aPPwwmt thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
Applicant who has not produced acceptable evidence of compliance with the insurance coversp required."ions stern
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth not any of its political sttbdivis
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 conWActing authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub cpnractor(s)name(s),address(es)and phone number(s)along with their cortificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance: If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmationy isrequ re insurance coverage. Also be sure to sign and date the affidavit. the affidavit should
be retained to the city or town'hat the application the
duns regarding the]awmoreif you are refit to obtain a wor being requested, not the kers'
s t of
Industrisf AccidentL Should you have any qu
compensation policy;please call the Department at the number Usted below. Self-insured oompanite should enter their
Self-insurance license number on the to Una
City or Town Officials
Please be sure that the affidavit is Complete and printed legibly. The Department has provided a space h the boron
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
in addition,an applicant
Please be sure to fill in permit/ticense number which wall beused a reference need only sub number. affidavit indicating current
that most submit multiple permitAicense applications in any f;n Y
policy infomtation(if necessary).and,under"Job 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>p 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 vesture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a c2l
The Department's address,telephone and fax numbs.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
� a
BOARD OF BUILDING REGULATIONS 1
IiJ(:6nw: CONSTRUCTION SUPERVISOR
4 ,bPw If
Number,: CS► 064786
r
f B�rtlldatsf0/07/1966 ;
a a ExplreiS 10/011200¢`e} Tr no:.3866.0
Restricted d
PETER A SHE PPA lti � .'
f 25 OSGOOD ST J e-
•_ �, ? SALEM, MA. 01970 . "` �:". /�
Commissioner
1 . - Board of Ball 1;4S ftg4lafmns and Standard
HOME Iryg,(t\OVEMENT CONTRACTOR�15t
- Regl_tratitoeit 147239 r
Expir l2 2007
TyP to,Corporation .e
AFFINITY CON UCTtOC_�„'.
R ¢ Yt
PETER SHEPPARD�, ` y • _� p
: 50SGOODST,
I f 4 —b—
ti
' 70:.':.._
r SALEM;MA09 . ,; itubirote�:._
CITY OF SALEM, MASSACHUSETTS
• • PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACNUSETrS 01970
STANLRY J. USOYIC2, JR. TELEPHONE: 978-748-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Pernut 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, S 150 A.
The debris will be disposed of in:
/f/U6�fnea� ('Arl f;y,, (Location ofFacili
Signature of Applicant
9
Date
N / F
Jeannette Realty Trust Zoning District: R2
AIsesap Assessors Map 26, Lot 82
Proposed Lot Coverage: 17% f
Deed Reference: Book 24572 Page 309
N / F NOTE: THIS PLAN WAS PREPARED FROM A
Mark A. & Leanne J. TAPE SURVEY AND IS INTENDED FOR BUILDING
INSPECTOR PURPOSES ONLY. OFFSETS SHOWN
Morin ON OR SCALED FROM THIS PLAN ARE
APPROXIMATE ONLY AND SHOULD NOT BE
USED TO DETERMINE PROPERTY LINES.
Assessor's Map 26 Lot 73
Area = N /"F
14442 %F..* John J. Kaitz
N / F
North Shore Heritage
Association Assessor's Map 26
Lot 83 -"4
tHOr"tip' .
Assessor's Map 26 $ ��� DAVID
Lot 81 PIWUP
TERt_N ONI
N0.38720
On dine A90 c 1Qy r
pps
15' .Ta Be
} PROPOSED
ADDITION
15'x22'
J
No. 29 PLOT PLAN of LAND
Dwelling
1 1/2 29 MASON STREET
Story SALEM, MA
124 Owned By.
65, Matthew Amato & William Bushong
SCALE: 1" = 40' FEBRUARY 6, 2006
MA S O N S T R E E T REID LAND SURVEYORS
365 CHATHAM ST., LYNN, MASS.
CONTROL #:R06-024 OPT
l 29 Mason St,Salem,MA
SIZE FSCM NO DWG NO REV
DRAWN BILL BLISHONG 1914 2
ISSUED 2-7-06 SCALE 1/128: 1 BasementlGarage SHEET I OF 3
�U
22,_0„
Elec#1
® Elec#2
Elec House
h ® ® ® ® C
Gas#1 O
'u Boiler#2 Gas#2 CO)
38,_0" �sv Boiler#1 N
t[l� O Fb i
G
� � OFloof2 IMP
E
uP C
Crawl Space
Garage - 21'_0'.
V�lt� du�.�hrn ('�{,'
0 ft. 6 ft.4.810.ft.8.0 in. 21 ft.4.0 in. PROVED c a(p
Subject tO
Scale:1/128:1 CITY of 5T
EV• Pal .za —
Ar�L-WITH THE FIRE CODE,
29 Mason St,Salem,MA
SIZE FSCM NO DWG NO REV
DRAWN BILL BLISHONG 1914 2
ISSUED 2-7-06 SCALE 1/96:1 11° Floor SHEET 2 OF 3
22,_0"
0
O
pt,
C O
`EEp[ >
J O
C �O
OuP J
100
I
O
�I C
- o
Hallway y
Ell 0
Y i ap` 'aUp
O Bathroom CD
® ❑ Porch
0 ft. 4 ft.9.6 in. 6 ft. 16 ft.
Scale:1/96:1
29 Mason St,Salem,MA
SIZE iSCM NO DWG NO REV
DRAWN BILL BUSHONG 1914 2
ISSUED 2-7-06 SCALE 1/96:1 2n°Floor SHEET 3 OF 3
22'-0"
\\\\\ o
� o
€ 0 Bathroom nm
IP
.._. '...a.,...�-�,.-....__.. ...--,.--... I
1
4
O ,�� Closet C
O
® O7 \\\ s \
o
t �� A
lJ ; XI
49'-9"
Oft. Oft.9.6 in. 8ft. 16 ft.
Scale:1/96:1
1
N / F
Jeannette Realty Trust Zoning District: R2
Assessor's Map 26 Assessor's Map 26, Lot 82
Lot 50 Proposed Lot Coverage: 17% f
Deed Reference: Book 24572 Page 309
N / F ie J, NOTE: THIS PLAN WAS PREPARED FROM A
TAPE SURVEY AND IS INTENDED FOR BUILDING
Mark A. & Leanne J. INSPECTOR PURPOSES ONLY. OFFSETS SHOWN
Morin ON OR SCALED FROM THIS PLAN ARE
APPROXIMATE ONLY AND SHOULD NOT BE
USED TO DETERMINE PROPERTY LINES.
Assessor's Map 26
Lot 73
0
K
Area = N / F
1$442 SF.t John J. Kaitz
N / F
North Shore Heritage
Association Assessor's Map 26
Lot 83q" '*Ma
Assessor's Map 26 8 DAVM
Lot 81 Niiup
TERDgIONI
No.387W
On one Aq�FES� �Pr
15' To Be V�
Remo+ed
,r: PROPOSED
ADDITION
.15'x22'
J
No. 29 PLOT PLAN of LAND
Dwelling
1 1/2 29 MASON STREET
Story SALEM, MA
,zt Owned By.
es Matthew Amato & William Bushong
SCALE: 1" = 40' FEBRUARY 6, 2006
MASON STREET REID LAND SURVEYORS
365 CHATHAM ST., LYNN, MASS.
CONTROL f R06-024 DPT
29 Mason St,Salem,MA
SIZE FSCM NO DWG NO REV
DRAWN BILL BUSHONG 1914 2
ISSUED 2-7-06 SCALE 1/128:1 Basement/Garage SHEET 1 OF 3
�o
22'_0"
31'-0„
. ® El ec#2
? El ecHouse
g
0
(Bs#1 O
y( Boiler#2 Q #2
38'0"
4
._ Boiler#1 N
9
Up
p S Floor 1
�Floor2
O Crawl Space
Garage .. _
r
Oft. 6 ft.4.870.ft.8.0 in. 21 ft.4.0 in. APPROVED u
Subject to spar.;'a_L- c-7 c'�"�Y
Scale:1/128:1 autho7".tE har-'a "_L:,.aiii,SG+l.
CJT�
FT�w mD'M.
L
PLAi.4 R. i�P`RLir-:J::uv .:2
TYFc AND L^..".�i0'1 Cr
A'.L FI'" PROTECT iON DE9:^_ -:B'10
7.LiL�i Ai: INSPECYION,FOt.CO!dFLE+-zC'..1:i'J-
Ah,-'E WITH THE FIRS CODE.
29 Mason St,Salem,MA
SIZE FSCNI NO DWG NO REV
DRAWN BILL BLISHONG 1914 2
ISSUED 2-7-06 SCALE 1/96:1 1"Floor SHEET 2 OF 3
22'-0"
t 31'-0
101� I
E
IT O
C
w E
J O k tT o
�
47/�p L co r
C
t o w
p -_. _.... ..
O
Q I
7n O 0 Hallway
n eV C:C O O
Y e c o
CTI
o 6,
o o tp I
0 Bathroom ; m ro
s® !o? Porch
0 ft. 4 ft.9.6 in. 8 ft. 16 ft.
Scale:
4
29 Mason St,Salem,MA
SIZE FSCM NO DVVG NO REV
DRAWN BILL BUSHONG 1914 2
ISSUED 2-7-06 SCALE 1/96: 1 2""Floor SHEET 3 OF 3
22'-0„
31'-0„
CD
IIv''
o
a
Bathroom
N
0m
50 C E ��, Closet C
N O
C� U �` O z swrese f H
�® 6 E ! \ \ E
ED O •� I A
N
49'-9"
0 ft. 4 ft.9.6 in. 8 ft. 16 ft.
Scale:1/96:1