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203 NORTH ST - BUILDING INSPECTION 1 J04 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT iJ.ela::Rtaiy DRIX:ULL Vt.\Yoit M WASHING TON STREET- • SALEM,1v1ASSACI it:.11i'1'is 01979 Tu_-978-745-9595 0 FAX:978-740.9346 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AoMicant Information / Please Print Legibly VBmC(F3u<itx/ss/,Organiratio Indivi�u _—b (ter el,A ��[v /�(� Address: `7 P1'c-,t /"77 4' v i /1'��1/q- City/State/7..ip:�//��'Y� U�� Y �A-- fJ/C1/i6 Phone Pr: al k— Wd Are you an employer? Check the appropriate box: 'Type of project(required): L❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction era loyces(full and/or part-time).` have hired the sub-contractors T Tnt a sole proprietor or partner- listed on the attached sheet. t �• ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I ani a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself.(No workers'comp. C. 152, §I(4),and we have no 12•F�l Roof repairs insurance required.) t employees. (No workers' // It— comp. insurance required.] 13.❑ Other �,/Atn( -Any applicant that checks box nl most also fill our the section W-uw showing their wurkeoa'compensation policy information. ' ltomchwm:rs who submit this affidavit indicating they am doing all work and then him outside comraeto s must submit anew affidavit indicating such. :Contracture that cimck this box most attached an additional sha:t showing the name of the subcontractors and their workers'comp.policy information. l run air employer that is providing workers'compensation insurance for my etnployeer. Below is the policy and job site bhformatiom Insurance Company Name: .....__.._-.__--- Policy#or Self-ins. Lie.K: ___— Expiration Expiration Dar — Job Site Address J /j_S Marll S)r_— City/State/Zip: � i . 1/q96 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 NIGL c. 152 can lead to the imposition of criminal penalties of a tine 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. Be advised that a copy of this statement may be forwarded to the Office of hnesligatiuns of the DIA for insurance coverage verification. /do hereby ce/rrti/f//��wider the pr 'ns and penaltiicccs afperjury that the information provided above is true andcorrect. Siem;nnre' Ey�.�lr'�( �6�" /A Date' /�,G' ?7 i i Pht ntc 3: '" official rise anfy. Do not write in this area,to be completed by city or town official. City or Town: _. Permit/License 0__._ Issuing Authority (circle one): 1. Board of llcalth 2. Building Department 3.Cilyff own 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 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,N1GL 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 nurmber(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 cant'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 he 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 pennitilicense 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 bur 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 u 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 0211 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia a CITY CrF SALEM I PUBLIC PROPRERTY DEPARTMENT \lArilt 12C W.\.91IXG:ONS,REET •SALD.I. MMSAt 1l iL11i0i91C TFt:97S.74i-4595 * F.--'c:978-74G9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5 Debris, and the provisions of v1GL 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 MGL c 11 l• S 1.50A. The debris will be transported by: - - L (tame of hauler) The debris will be disposed of in Olurne Of facility) �G iad.lresa ,li fucilay) .alp - PROPOSAL PROPOSAL NO. SHEET NO. _ �Q PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT DATE NAME - ADDRESS ADDRESS - - DATE OF PLANS PHONE NO. _ / ARCHITECT We hereby propose to.fumish the materials and perform the labor necessary for the completion of YJ9 A ! ti G ,- a ✓ // ! ,v' r /,�� T All mateyal Is guaranteb) tote s spec"41 the ab ve work to be performed in accordance with the drawings and specifications submitted for above/�/k, and complet�e'd/_/q a substantial workmanlike manner for the sum of _�P_ //z-r� �/ H vL5/l t�� h✓� �7y� dk-� � � Dollars ($ r �� with payments to be made as follows: s Respectfully submitted �� •a �� c�� G� Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note - This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date D r7 Signature DSDEI USA PROPOSAL EI'I�6F -- PUBLIC PROPERTY DEPARThIF.►'�tT KINGWALEV ORLSCOLL MAYM 130 WAsHiNGTm b%mEEr# '„&W N.ttuouse»s01970 Tti-97L74S-9S9S*FNC97L7404W APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION, DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR WELDING 1.0 SITE INFORMATION j Location Name: molding: d ld1990 Properly is located in a;Conservation Area Y/N�L—Historic District YIN-41- 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: d NIT 5*e L'7a 9 o Telephone: - - 3.0 COMPLETE THIS SECTION FOR WORK IN UILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of O Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: ,Trip 9,orarF 11,11d 12e P,7-dF --- - - ---Mail Permit to: I l��r ✓ r4. /�1f� 01��Q - - - -- What is the current use of the Building? Material of Building? �� M�dwelling.how many units? O- �9 WiU the Building Conform to Law? Asbestos? �Ar d Architect's Name Address and Phone _ ( ) Mechanic's NameLc ��r1 �n— Address and Phone. � /an.&-�fi� �� r' /i �So�v • M�-- O(� � 6 Construction Supervisors License 0 HIC Registration Estimated Cost of Projed Pik Fee Calculation Permit Fee f Estimated Cost X$71111000 Residential - - -- — - -- Estimated Cost X$11/51000 Commerc(ai- An Additional $5.00 is added as an Administrative charge. Make sure that all fields are property 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 o IL y U x � a