8 N PINE ST - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
\ter DEPARTMENT
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!v Ayolt 12^.WAsHlwTON STREET • SALE-M,MASSACI n;ll:l TS01970
'rtt:978-743.9593 • FAX:978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Co Please Print Legibly
Name tUusilless/Organiz ' YIndividual): (� /�)�A/, l
Address: 131k 1265
7
City;Staie 7_lp: ( Phone 1J: (003 r2cf 61ULo k
Are you an employer? Chec t c appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
6. New construction
employees(full and/or part-unic).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
I No workers'cutup. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.Q Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. (No workers' comp. c. 152,§1(4),and we have no 12. R repairs
insurance required.] t cmployees. [No workers'
13. Other
comp. insurance required.]
•Avy applicant dial checks box#1 must also lilt out the section below showing{their workers'cumpur alrion policy ioturmation.
'l lomwwm;rs who submil this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating uteh.
�Contracton that chsek this box must adached an additional sheet showing the name of the subcontractors and their workers'comp,pt ticy information.
1 ram car employer that is providing workers'compensation i isurunce fur dry employees. Below is the policy and jab.site
infortmrtiolL /�j/
Insurance Company Name: l � /.'`. AL............
-------
Policy#or Self-ins. Lic. #: 0.11, n ...__.. .-_.--_ Expiration Date: 2-42 3?
Job Site Address: "Nvr�� �l&P t City/Statozip: r l'r nftP 414-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure m secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tins up to S1,500.00 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. Ile advised that a copy of this slatcment may be forwarded to the O17ice of
Im cmigaliuns of the DI for insural:ce cnvera.e verification.
/da hereby certify t der the pains and penalties of perjury that the infurination provided above is true and correct.
51L':lllltt Ne Date: /
Phone:#: 2 (9 Z
Official use only. no not write in this area,to be cuupleted by city or town official.
City or Town:
Issuing Authority (circle one):
I. tluard ur health 2. Building Department 3.City/Twin 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."
:I,n 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, 325C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfom'tance 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-contractors)name(s),address(es)and phone mmnber(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 confrmiation 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 till 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/licensc 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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
i'hc Otlice 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
- PUBLIC PROPRERTY
DEPARTMENT
12C W.\iI IING:JvSiAEET 5d[i'\11,MASSACit A:11i]:9/C
Tet:973-7431)595 •P.at:971-74G9B46
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n accordance with the sixth edition of the State Building Code, 780 CNIR 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 defined by .1GL c
I11. S I50A.
The debris will be transported by:
(name of hauler)
the debris will be disposed of in
_ AfM_1a6
Wayne of facility)
Iac:Lty)
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PUBLIC PROPERTY
DEPARTMENT
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MM.M74"S"•FAX 97L7469M
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUP NCY FOR ANV F.]iQSTING
STRUCTURR OR BUILDII�t(_
1.0 SITE INFORMATION
Location Name: Building
Address:- .
if1�12f� r/1 r' d)t _
Property fa located in a:Conservadon Area YIN Hstarie Oistrld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address:
Telephone: len (, o 66
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I New
Brie(Description of Proposed Work:
fi`-fp elIC4 rP,
msl, q 3 fkc�/skits
-- - -- Mail Permit to:
What is the current use of the Building? If dwelling. many units?--
Material of Bu'�Iding? Asbestos?
"I the Building Confom+to Le"?
Architect's Nairn
Address and Phone
Mechanies Nairn A j/ 16j36?S
Address and Phone illyn
Construction supervisors License HIC Registration
Estimated Cost of Project S /f �i Perrnil Fee CateuMdOn
Permit Fee S //O' � Estimated Cost X$71411000 Residential
Estmated Cost S11/5100O CommerWl-- -
- - - An Additional$5.00 is added as an
Administrative charge.
Make sure that ail fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Buildings eermlt to to the above aled
specifications. Signed under penalty of perjury
Date ®)
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