210 NORTH ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compeasadoa Insurance Affidavit: Builders/Contractors/Electrietans/Plumbers
Aonlleant Information Please Print Legibly
Name t0ttvncssK7rganinrroNlndtvtdtnl):f'S ,cli�f�-!�'IO (J//�///fOIfGN /` .� �i/ /�!l
Address:
City/StateJ2ip:
.Are you sn oaptsyar'Cluck the appropA IRS box Type of project(relps red):
I.Q 1 as a cmpioyer with 4• Ll1J a�a ycnctal coulractor sad
empluyccs(full andfur part-tine).• have hires!the sub cwuractors 6' ❑ New conxtntetian
2.Q 1 am a silk proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling
ship and have no clnploycous Than have a. Q Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑=1d fig addition
Inn workers'comp, insurance S. Q W�are■corporation and its 10. Electrical
required) officers;have exerciaal their ❑ repairs or additions
3.Q 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbins repairs cur additions
myself.JNo workers'comp. c. 152.#1(4).and we have no 12.0 Raof repairs
insurance required.) r employees.LNo workers' 13.❑Othn
comp. insurance requircd.J
;airy.pisfcam Uar chucks boa II mot also An me an soil r In:lmr Amwisy thir Watkins,arrtpatWite puhey inGvotow eq
I IwtwwnMs who submit this enldwil isWieating Nq ate deice se wank anti Nee him antics eoauoctas men aulomil a asna il iftwil indicttina vetch.
:C,,Cratwa Mao drugs this boot mutt il"wind no adchupW Am Jlowiry the rwme tithe alh•eomadors sad their wurkos'emsp.pu0ry infitnowdus.
I ate an carlptoyer that is pravld/ns workers'compeasadoo lnsaraaee for my employees Below is the puNcy and Job site
inforial"i r" .. ._.
Insurance Company Name:
Policy e or Sclf-its. Lie.A: d g�F Q O160 Expinnion Date: 5 - 3 0 -
too Sitc address: !:�,> to ti� CitpSlateizip:_�(
rtach a copy of the workers'compensation pulley declaration page(showing rho policy number and expiration date).
FaiJura w wcure coverage as required under Section 25A of.1GL c. 152 can lead to the imposition of criminal penalties cfa
lino up in S1,500.00 and/or one-year irnprisrtnincnt,as well as civil penalties in the form ors STOP WORK ORDER and a rise
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be tunvarded to the 017ice of
Im sttgaum>r ol'the DIA .'or insurance covcra.c ceriftcatiun.
1 do hereby certify undeZ pain and pe llks of perfury that the infarwat/oa provided above is true and correct.
011kiad use only, Ib wilt wr✓p 1a rAb area.ra be rawpleteid by elty ar totem offlel"L
City or 'fnwn: Yermit/Lleease Y
Ivsuing Aulhurity (circle otu): —
1. Iloard of Ilealth 2. Building Ovpartmcnt 3. Cily/fitNa Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
C"nitacl Perron: _ Phone It
Information and Instructions
,%lysachusetts General Laws chapter t 52 requires At emptoye� ov ade workers'nother coder any comrade of hire,
ompensation for thek employceL
Putsuam to this staruto.an employ"is defined n*...every pat
eapress at implied,Oral of written."
An eeylOyer is defined a. ..individual.parttand inc
p.ammaooa,corporation a other legal entity,or any two or man
Of the foregoing engagod in a joist errerpruw,and ioelttam the leper Vj coci y.employing
i deemplo employer.
However the
assoeiadoO or other legal entity,empbYina emPloYeea
receiver es rushes of as iudividthsl,parmorsbhp. tone and who resides therein.or the occupant of the
owner*(a dwdTioa bones having not stets than apsroatrtws
dwelling house of another who cmPIOYs Peras so do maintenance.cuostrhrcdan of repay won't on such dwelling housem
or on the grounds at building appurtenant dwom shall not because of nte►awfloymee t be deemed to be an employer•"
.ktGL chapter 132.425C(6)also states that..„very stab or bed Ucoasfni 990ary stag witbb*M tN'"Alsace Or
b o Alb a business or b eoustrud buildings Is the commoswoam for say
re°ewd of s e isms of Perpes uc� �eptable evidence Of comPUasm wkb the Insurance coverage required."
epplleast ty. GL task peed of its political subdivisions shall
Additiomlly.MGL chapter 152,§25C(7)staoes'Neither the coaunertesealth nor easy t>b . .
enter into any contract for the performance of public wort until acceptable evidence of cO mpliance with the insurance
requirements of this chapt
er have been presented to the contracting authority.-
Applieans
Please fill out the workers" compensation affidavit completely.by electing the boxes that apply to your situadon sad if
co�aCtor(s)nane(s),ad es)and phone nut is a)along with their certiticate(s)of
necessary.supply LG�a Limited Liability Partrershipa(LLP)with no empka an other than the
insurance. Limited Liability companies(L �, [fan LLC a LLP does have
members or partners.are not required to carry waken componsadOa
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 sip sad 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 Dopsrtaent of
lnduso,W Accidents. Should you have any questions regarding the law or if you are required w obtain a workers'
comperuation policy,please call that Departso at at the number listed below. Sclf-insured companies should enter their
.elf-insurance license number on the approcrials line.
City or Town Officials
Ptcase he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you o fill out in the event the office of Investigations has to contact you regarding the appliconL
1'Icase be sure to fill in the permrit/license number which will be used as a reference number. In addition,an applicant
the mua:t submit multiple Penmit/liccnsa applications in any given year,need only submit one affidavit indicating current
policy information 1 if necessary)and under"Job Site Address"the applicant should write"all locations is_(city car
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 a licenses. A new affidavit must be filled out each
year• Where a home owner Or cidzcn is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn laves ern.)said person is NOT requited to complete this affidavit.
I'hc Ot uce cat'Investigation would hue to thank you to advance fur your cooperation and should you have any questions,
:cane du nut hesitate to give us a call-
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oake of lawstlpdOw
600 Washington Strew
Boston, MA 02111
Tel. M 617-7274900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
2cvi>cd i �� os www.m&w.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Constructiat Debris Disposst Alhdsvit
(requuwl Ito all danoddon and sonovatias work)
is monlenes with dw sixdt edition►d dw State Buiidins Code.730 CAl1A soctiatt 111.5
oar*and dw provisions of M. GL a se.S sk
gtrildl„S Ponnit 0 _ _ is issnd with dw eoodhim that dw debris rra dtin4 Am
,his wonk shall be disposed or in a propcty licensed waste disposal Itwility as dolled by MSS,e
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The debris will be transported by:
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rho debris will be disposed orin :
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Approve Final Design
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PUBLIC PROPERTY
. DEPARTMENT
KI%MEMAV DRACML
4AYM 120 WA5M MGrM 3_nM= yurx MwsUats&-rR 01970
TO-TWUS-9"S• PAX 978-740-98"
APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION,
DEMOLITION. OR CHAINGE OF USE OR OCCUPANCY, FOR ANY EMSTING
STRUCTURE OR BUII.DING
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1.0 SITE INFORMATION
Location Name: Building:
Property Address:
-a rb 9� 4Y- JJat�
Property Is located in a: Conservatlon Ares Y/N Historic DIstrIQ Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: J 4 )y (r/1 ZT 1 /L(S ._
Address: 3
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation I� Number of Stories Renovated
Change in Use U New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
EkW Description of Proposed Work:
Mail Permit to: �c�l e°r� J jr7/Il>>Soiy 3Groz/--f
_ .
ry�T-
What is the current use of the Building? ✓7) /
Material of Building? Anne {po If dwelling. w many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( 1
Mechank's Name F '^
� G`6 5235 6�
Address and Phone 3 �I 19/Sn tii A vI-' o I 3 / �j
Construction supervisors License M a�cy HIC Registration#
I , Estimated Cost of Project S ' °j L/ Permit Fee Calculation
Permit Fee S Estimated Cost X$7/51000 Residential
Estimated Cost X S11/111000 Commercial
An Additional $5.00 is added as an
Administrable 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 t dhe a ;ve stated
Lzjyd��—.
specifications. Signed under penalty of perjury X
Date
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