19 NURSERY ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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TEI:978.743-9595 •FAN:978.74Cr9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of M. GL 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 defused by v1GL c
111.S 150A.
The debris will be transported by:
Wait of hauled
fhe debris will be disposed of in
(lame of facility)
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"�� CITY OF SALEM
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XI\1a::RIXY DKIR:OLL
\1 XYoa 120 WASHING ION S,rRELI' • SALEM,MAss,u.rIUSE I ISO 1970
Tta.:978-745-9593 rr Fax:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information __Please Print Legibly
Name (tau<ill"s/OrganizatioNlndividual): S
Address: nV0 � 4 1,1`�
City/Sratei7..ip: Q�- INN '�N Phone #:
:kre you an employer?Check the appropriate box: 'type of project(required):
ltiil1 am a employer with— _�\ — 4. ❑ I am it general contractor and I 6. ❑ New construction
employees(full and/or part-tine).' have hired the subcontractors 7 ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t
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 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 1 1.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work. S P P'
myself. [No workers comp. c. 152, §l(4),and we have no 12.❑ Roof repairs
insurance required.] t cmployccs. [No workers' 13.❑ Other
comp. insurance required.]
'Ally applicant that checks box ill must also lill out ihesectio,w,ow showing Ihoir workers cumpolnation pulicy infurmatiun.
'ttomarwm:rs who submit this affidavit indicating they are doing all work and then hue outside conrmclom must submit anew uI ridavii indicating etch.
-Contractors lhal check this box must attached an additional.sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am atr etaptoyer that fv providing workers'eompeneation insurance for lay employees. Below is the policy and job site
information. ll''�
Insurance Company Name: __D_11- —
Policy a or Self-ins. Lic. t;: --__....__..______—__ Expiration Date: C�
Job Site Address: �� J`l`""-aA rr\ " City/State/Zip:
Attach a copy of the workers' compensation policy tYeclaration 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance ccvcrage verification.
l do hereby certify under the pains m�ies of perjury that the information provided above is trite and correct.
SiL t our i D nc 7
phone f:
Ofjic•ial use only. Do not write in this area, to be completed by city or town ofjic•ial.
City or Town: .. Permit/License _.-----
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.Cityffown 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 enipletyees
Pursuant to this statute,an etnplgree 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, 'v1GL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomnance 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/licerse 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.
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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/time
PUBLIC PROPERTY
DEPARTME►�TT
1
A1.�01F.Y�Y D�isry�
%"YM
130 WASUNGWM b%VE4T•!MMhL.MA9L%0MSM-TS 01970
T41.M?45-9S9s•FAX:97L740.98"
APPLICATION FOR THE REPAIR. RENOVATI N CONSTRUCTION
DEMOLITION, OR GRANGE OF Uc>e OR OCCUPANCY. FOR ANY EXIST NNG
STRUCTIII>$ OR BUELDIN
1.0 SITE INFORMATION
Location Name: Building-
Property Address:
Properly Ia bcafsd In a:Consavatlon Aroe Y/Q Histoft DMId Y/R>
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: "
Address:
Telephone:
V3.00OMPLETECTION FOR WORK IN EYIATING BUILDINGS ONLY
Existing
Number of Stories Renovated
New
Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: n
-
- - -. - Mail Perrnit to: a 611 6
What is the Current use of the Building? units? N
Material of Building? �?oo� If dwelli rm
dwelling.how any
WiM the Building
Conform to Law? Asbestos?
Architect's Name
Address and Phone �C
Mechanic's Name �ss O q
Addre and Phones
Conatrtacfian Licanss HIC Reglatra
Estimated Coat=of�Proje�ct�S �=� Permit Fe Cak,ulerion
Perrmd F Estimated Cost X$71$1000 Residential
Estimated Cost X S11I:1000 Commercial---
- - - An Additkxal $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 pw mit to build to the above stated
specifications. Signed under penalty of perjury X .�
Date
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