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8 NAPLES RD - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPRERTY err /j DEPARTMENT KIMRERLEY DRISCOLL MAYOR 120 WASHINGTON STREET ♦ SALEM,MASSACHUSE'I'TS 01970 TEL: 978-745-9595 * FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name (Business/Organization/Individual): a\� OS a�-O Address: )9— tP lC rL<cv.� ST c City/State/Zip: Wpl,L ctt_ �1&, ot4Z� Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. 21 1 am a general contractor and I 6. ❑ New construction f 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 ® Remodeling 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' comp. insurance 5. ❑ We are a corporation and its I0.® Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I Ln 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.❑ Other comp. insurance required.] -Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this hnx must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'cotnpensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: 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 tine 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 S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. \� I do hereby certify under the pains and ettalties of perjury that the information provided above is true and correct. Si,,nature: Phone#: Official use only. Do not write in this area, to be completed by city or town official. 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#: 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 in ajoint 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 the 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 Town Officials 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 fill 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 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.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 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. # 617-7274900 ext 406 of 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia i CITY OF SALEM ' PUBLIC PROPRERTY DEPARTMENT \l .n1K 120Vt.Kiln\t;:o�SiREET4S.\Li%t, St.�u.�<:',u ,ECIS :91C Tel:979-745-9595 * P.kX:979-74C.9M Affidavit Debris Disposal � Construction Debr osal p (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 ChIR section 111.5 Debris, and the provisions of vMGL 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 viGL c 111, S 150A. The debris willbe transported by: - (name of hauler) The debris I%ill be disposed of in (na6le of fal;ilrty) _ � \ o w Vn f farti,rJ)—�_ The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street `r Boston A L4 02111 Workers' Compensation Insurance Affidavit Applicant Information: I'it Property Owner Name: �( � U tY V>°- b o U-c'c Job Location: y� City: V\A, . Phone# pv7��3 ❑ I am a homeowner perforniing all work myself. Q(I am a sole to rietor and have no one working in any capacity. ❑ I am an employer providing workers' compensation for my employees working on this job. Company Name: Address: City: Phone# 4 ` �=ems. Insurance Co. Policy# I am a soleproprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: - -Company Name: Address: City: �4�u Z S M I�', Phone# . 6/7�C-77r)-- ii(0 1 Insurance Co. } Policy# — 2 Company Name: �OS a`�p �y\-CL-�`5 C— Address: ? �j l�o x '79 S 1: Vt A . City: �P Phone# G 03— f)3 y— a87� Insurance Co. Policy# tlae additiana.s -- Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pa' s and e of perjury that the information provided above is true and correct. c� Si at - Date z —t�u—� Print Name \ `1 © S 4—�G Phone# RBI�S` ( 6 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/license# ❑Building Department o Licensing Board ❑ Check if immediate response is required o Selectmen's Office ❑Health Department Contact person: Phone#: -4a - ❑Other The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR a, MUNICIPALITY V➢V Massachusetts State Building Code, 780 CMR, 7 edition USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Num r: Date Applied: Signature: Building Commissioner/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: J Zone: Outside Flood Zone? Public LN Private❑ — Municipal f�On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIPt 2.1 Ow ngr of Record �VDI1=s -f>Q d =Cl G l� Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing BuildingX Owner-Occupied Repairs(s) 'K Alteration(s) 10 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work 2: VJ G W sTe� Ce a , -rC r� Iyeao 3 cc — riT L©of 1�cv+ate[ T d w tk c,(r. OVtr cgyrvr 7S a a c(, ou.e hew oytr Citn� t'.Jn© k caps es ov. gecv�4 c.t' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 C, o o ,i 1. Building Permit Fee: $ , 7 Indicate how fee is determined: 2. Electrical Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ y oG t 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ --3'7fP deck No. I gLko Check Amount: Cash Amount: 6. Total Project Cost: $ ,�3 O�Gr ❑ Paid in Full ❑ Outstanding Balance Due: A-A/4 1V07WV1 17~q ?'6 P47 S "/ k*11_FW f'-h , "4_ 0(4z3 Ak SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) &7 L �oS a (=D License Number Expiration Date Name of CSL-Holder /I p �'J g �� c� S-�v�l ��• t�tN1n[t 1i✓I List CSL Type(see below) R Type Description U Unrestricted(up to 35,000 Cu. Ft. R Restricted 1&2 Family Dwelling pt� Signature M Masonry Only .7�1 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Homer a Improvement Contractor(HIC) Fa (,al-t ' Kos a iZ o //1 S`I 7 HIC Com$$ y Name or HIC Registrant Name Registration Number 7d t�IcaStw'T STD wty.l..aw. Ad �d -is-a9 q Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION,7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT QI, ! (.(' as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authoriz d by.this building permit application. Signature of&Xvncrr ' ' Date n SECTION 7b: OWNERS' OR AUTHORIZED AGENT DECLARATION< I; � 1 , +A as Owner or Authorized Agent hereby declare that the stateme a form the foregoing application are true and accurate, to the best of my knowledge and behalf. o..(, a i; Print Namc Signature of Owner r Authori Agent Date (Signed under the pains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage, finished basement/attics, decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for"Total Project Cost"