141 NORTH ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tiovutr steer uaea:sxi
Msrsta 12C V/AS&%irmStsear is Sit lt?al,U\atACY a a'rss 019T,1
TILL 978.745.95" a FAX:97a•740.9946
Workers' Compensation Insurance Aflldavit: Builders/Contractors/Electridans/Plumbers
Annllcaat Information ] Ptease Print Legibly
/
Vane tlluaitw:attl(kYattirariwlttdtv,sltnl)I , .) P l 0l ..I� ]1
Address: �(�( f�is �lt Aid
City/St31Wzip: a,/,-, lunetl: 5ci2 /APR
Are ro to employer'Cheek the appropriate boa: FoRemo&linj;
ect(required):
1.Q 1 am a employer with & 4. Q 1 am a general couttanor a"Ionstruction
arnpluycea(full and/or part-time).• have himd the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t eling
ship and have no employees These have itionworking for me in any capacity. workers'comp insurance(too workers'comp. insurance 5. Q We arc a corporation and its g roklitiom
required) ofcers have exercised their . ectrcal repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.#1(4).and we have no 12.Q Roof repair
insurance requined.j t employees. [No workers' 13.❑Other
comp. imsurance required.]
•Any Vpkad dW chucks nos el man also as ant One seenioo bclmtt rharine thew tvtmlas'cwnpmWkM pulley iolimswiod
IIIusnw,wnre who subinil cis sJ%&wii indic uml;awry ate duiq eg mMt mia this bite do,"ee on ram,saw.u6mk a rill,armies imliarina o,r•►.
1117a,timA rs this chock Ills box must anaelmd an addiUmnl Wit showins me ram orate me wawagote seed thew withers'comp.policy fmrtmmsnon.
/oar ua employer that is providing workers'compensadoa liunrertee for my irtfarmrmf" randJob stop/uyrrs Below ow Is the pit alti,
, , ._
Insurance Company?lame:2�/�e� �✓n� _• ._
Policy M or Sclf-ins. Lic. x1: 1'3 64" C"—1G,9 _ .. EApirauon Date:_ 1 -I(-6P
Job Site Address: /4/ ,ie/0 A .s/— City,StatuZip:.-: f,4 , Ike r'',tS �ZL
Attack a Cully of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.IOL c. 152 can lead to the imposition of criminal peruiltiesora
ri All: up it)51.5110.00 and/or one-year imprisonment•as well as cavil pcnalusx in the form of a STOP WORK ORDER and a foe
of up to 3250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the OAice of
Inve�ngmuau ufthc DIA for insurance coverage vcrifteatiun.
/do hereby certify altder the puiar and penulrler of perjury that the infworalloa provided above it sue mild correct
<i•:,:our.: // ��' Date•
PM nee q: ''-
U/Jlaial mrs unry /M cot odic!a thb area,to bi rosrp/t/td by r/ry or rotrle o/j/i lmL
City or 'rosin: Permit/l.lecase 0
Issulag Aulburily(circle one): --
1. lluud of llealth 2. Building Department J. City/fora Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: _ Phone p
Information and Instructions
piasstchusetts General Laws chapter 132 requires all employ rsttop%viservice u another under any orlicts' compensation for theiaet of hi t
Pursuant to this statute.an fmAyee is defined as'...even person
etpress or implied.Ural or written."
assOdMiea,corporation or other legal entity,or any two a am
• n eavlayer u ddfised es"as 'P the le representatives of a deceased employer.or the
Of the foregoing engaged in a joint aatetprise and including eP to o ees However the
assoeiatuw a other legal entity.employing tpl Y
receiver of uustes of m individual,PecmershtP' and who resides therein.or the occupant of tba
owner of a dwelling house having uwt morn than three maintroab
roan ro do maintenance.cumsauction o repair work an such dwelling house
dwelling douse of another who employs gee be deemed to be an employer."
or on the grounds at building appurtenant thereon dha11 not because Of such employment
IviGL chapter 152.423C16)also states that"every state or local Uetashall agency a" the issusaee or
too rate a business or to construct buUdUW In the commoaw*&"far say
reaewat of a Itcease or permit to with the�yn�coverage require!."
appWast wise has sat ptodaead acceptable evideaea of a ommons
Additionally.MGL chapter 152,$23C(7)states"Neither the commonwealth nor any of its political with di ins shall
enter into any contract for site performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applieaatt
Please fill out the workers'compensation affidavit completely,by check
the boxes that apply to Your situation and,if
necessary.supply wb c°naacror(s)name(s),addsess(as)and phone number(s)along with their certifica�s)Of than
Limited Liability Companies(LLC)or Limited Liability Partnerships(L.LP)with no employ
the
membeea red m carry workers•compensation insurance. if an LLC or LLP does have
members or Dormers,are not required Department of Industrial
employees,a policy is required Be advised that dnu affidavit may be sign
adsubmitted to the affidavit.
Accidents for confirmation of insurance coverage Also s� l to ice�ases�s'seine requested,nested,not the Oeparonenn should
be returned to the city or town that the application for the permitg eq
ladustrial 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 lusted below. Self-insured companies should enter their
self-insurance license number on the aPprupr4telam•
City or Town Officials
please be sure that the affidavit is completi'and printed legibly.-The Department has provided u space at flue 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 17,11 in the permit/license number which will be used as a reference number. In addition,an applicant
thug must subunit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Addrese"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
Where a bo owner or citizen is obtaining a license or permit not related to any business or commercial venture
(year i.e... dug license dog
a permit to burn leaves etc.)said person is NOT required to complete this affidavit
-
a Otitce of Investigations would "c to thank you in advance for your cooperation and should you have any questions,
picabe du nut hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachtlsetls
DepaRment of huhilitfial Accidents
o les of lavesdviden
600 Washiagooa Street
Bosto%MA 02111
Tel. M 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Zcvised 5-26-05 www.mm.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
?Etta a l3l'7.t9 N::anS 7tST�;tti f1.11a 4ut:a I::9 r.
Construction Debris Disposat Affidavit
(required for all daaolidon and smovad"waft)
la aoconlartce with dw sittdt edidost of the State Building Cod@.7SO 0611 section It 1.5
Debris.and dw provisions o(M. CL c 40.S Sk
Suildin{Permit dam_ _ — is iswtad witb th@ condition that the debris rat ditg dam
&his work shall be disposed of in a properly Beamed waste disposal fbality as de}lned by WI.c
III.S15"
The debris will be transported by:
_ tnom.at hsdM
rho Jcbds will be disposed of in
,44"f %o t—Z7gy)
..AM
EITY"OF •
PUBLIC PROPERTY
- 's
DEPARTME,�T'T
KwswavaamaL
„�. 130 WAS MAM M snag.LUA04 XAMM3LWM GIVM
AlPI.ICATION FOR TBZ REPAIR. R—MNOVATiA rN CnNRTQit["rinN_
DIMOLMON,OR CHANGR OF USZ OR OCC MANrv_ Fog A NV =!r U
4TRC��lm n
1.0 ISTE INFORMATION
Location Nana
-- �IV --- --- -- — — --- - -
Properll b bcobd Ina:Ca+wvadon Anu Ytk) illft DlaMbt
2.0 OWNERSHIP INFORMATION
11 Owner of Land _
Narrw L< srd Cc. ess.
Addrvm
&DCOMPLET5 THIS SECTION FOR WORK IN mums Ilia BU LDINOS ONLY
Addition Existlng ,Z
Renovation Number of Starks Renovated
F
Use New
n meting
te year of Area per floor(st) Renovated
on a renovation building New
iption of Proposed Work: re,�,ems: ! c 67 a3 l� i CL9s. 5� �'vc'r �-� �'� JL�C is �• ("
c'c
--- - ---Mail Permit to: 47 r
�G S
What ks Uts Doren use of the I it dwetlinp.haw many unUs9
Material of bbiu�dMq� i
WE Me&A&*COOM to lamb ✓s Aabestos9
Aroht $Name � ' —
AddraNs and Phon*
Madwds's mars
Addr«s and Phone
ConaMiclion SLVWvis t3oeroe d � 2 Fee
RepidraMon
sor
Es*nard Coat at Projsd! 1 ccxy Psrrrrlt F«Cala+lalbn
Permit F« L
Es*nmftd Cost X$741000 Reebdentld
--- - ---_ _ - Esllna/fad Cost X i1 1/:1009 Conwnsrda4 --— --An Additional S&OO is added as an
AdmkO*000 cAarpa.
Make sun that ap fields am propwV and IsW*w Man to avoid delays In proaessinp.
The u ,dsrsipned does hereby apply*w a Bu"M Permit to build to tit atww stated
specr4adons. Sipped under penalty of pgwjLrY �
�I
3
v
..� d