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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.tst�x 12C 1 SALVM. %IAYiAC%it �IL CIS]:91:
'rF..t:978-745A595 •FAx:978.74G9846
Construction Debris Disposal Affidavit
(required fur all demolition acid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as define by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
I'lie debris will be disposed of in
4 �i�
(uame of facility))
. . adi'resa ot'fuci�dV) .
,i_r.ntuca ou'%It app.icam
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:AAtlli[R LIiY DRIN.:OLL
MAYOR M.WASHINGTON S'rltecr •SALP.m,MAssna wsp:rrs Gf97^
Ttsl.:978-745-9595 4,FAX:978-740-9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
♦nplicant information Please Print Legibly
Name (Bu<iness/OrganizatioNlndividual): �tl R�2�14/9 Aa T"/"
Address: G/ 13LI COn-1 9Z
City/State/Zip: VU j! (yl LA'hone i:: a �7` S� S` r�
Are you an employer?Check the appropriate box: 'rype of project(required):
L❑ 1 am a employer with 4. El am a general contractor and 1 6 ❑ New construction
mployces(full and/or part-tinic).* have hired the sub-contractors 7. ❑ Remodeling
1 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers'sump. insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions
rcquirud] officers have exercised their
3.❑ I ran a homcownur doing all work
right of per MGL 1 LE] Plumbing repairs or additions
. g exemption Pon
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any:µtplicou dint checks box ell must also fill out the section endow showing their workers'cumpenution puliey information.
'llumatwm:rs who submit this a ffidavir indicating they are doing all work and then him omsid<cummetors must submit a new affidavit indicating such.
�Comnctun that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
l run un employer that is providing workers'c•ompenealion insurance foe•mty employees. Below is the policy anti job site
information.
Insurance Company Name:---..---...........—- ----__--.-
Policy k or Self-ins. Lie. t,': _.___.__._....._____._ Expiration Date:
Job Site Address: City/Stan/Zip:
Attach it 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
tine up to Sl•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 S250.00 a day against the violator. tle advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance ecrverage verification.
l da hereby certify
yyJunder the pains road penalties ofperjury that the information provided above is true and correct.
Signature: _z&l ��� Data
Phone Y:
Official use only. Do toot write in this area,to be completed by city or town official.
City or Town: _ Permit/License tl----- -------._.. —
Issuing Authority (circle one):
I. Berard of Ile:dth 2. Building Department 3.Cityffoxsn Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other --
Contact Person: _._-_ --_—___---- Phone h:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.4
Pursuant to this statute,an emphgyee 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 in 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 employees. 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 appurtenant 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 coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
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 authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking tine boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or'PowmOfticials
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.
Please be sure to till 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"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 to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a hone 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 etc.)said person is NOT required to complete his affidavit.
The O 'ice of Investigations would like to thank you in advance for your cooperation and should you have soy questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05 www.mass.gov/dia
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EIT7OF .E1C
`Q PUBLIC PROPERTY
DEPARTME1�tT
u ONSLEV ONSCULL
%(Avon 130 WAMONGWW alcu err •• MAZACH -rM 01970
TM-M745-9"S•FAx:V&740.96 %
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR WELDING
1.0 SITE INFORMATION Aip /-oT 6060 5�S�650,js rk
Locadon Nam« 6 AV Fr,T,T AO P Q Building: S' h y c- ,
— - properly --
41t, hoof�q G1
Properly In located In a;Consarvallon Arse YM Historle Otatriot YIN
2.0 OWNERSHIP INFORMATION
2J Owner of Land
Name: f1q c d� �acvn
Address: itb Kvj,fst - (Lo v
Telephone: 97 Q J-2-�4
✓ 3.0 COMPLETE THIS SECTION FOR WORK IN EYISIINd BUILDINGS ONLY
Addition Existing �2—
Renovation no Number of Stories Renovated r)D
Change in Use 00 New n 0 y0G
Demolition N p Existing s "(
Approximate year of L
ea per floor (so Renovated
construction or renovation 19 y rX �1
of existing building New �p S
Brie(Description of Proposed Work: r
e (� X / Z $herd /� tfnclfep � G
vo'l n w wS
Mail Permit to: S'� ��+/cow /� S�° S'Ale i-t.. t%q all }�
What is the current use of the Building?
Malarial of Budding?INOV If dwell how many units?
Will the Building Conform to Law?
y� S Asbestos? /Lotl�v aw,.r
Architeds Name
Address and Phone I )
Mechanies Name !a y� p-J,rFY�i
Address and Phonec.S R I c� �i S
construction Supervisors License 3 -7 9 Q k HIC Registration X
Estimated Cos Pemdt Fee Calculation
Permit Fee S �� Estimated Cost X$7/$1000 Residential
- __- . --- - -- -- _ -_ -- Es*nated Cost X$il/:1000 Commercial--
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury /�
Date a
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