54 OCEAN ST - BUILDING INSPECTION i
r CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦ SALEM,MASSACHOSEF['S u1970
TEL: 978-745-9595 ♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: S 6/ OGeQ j? Sfi
City/State/Zip: rn !22a 014'd �— Phone #:
Are u an employer? Check the appropriate box: Type of project(required):
1.Are
a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. t 7. ❑ Remodeling
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 required.] of L0.❑ Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ 1pof repairs
insurance required.] t employees. [No workers' 13.F040ther 4
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
!ton an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: '/5 -r't-Ih�>•. /
Policy#or Self-ins. Lic.#: In/G L./39-- /K— 39 Expiration Date: I%L L/ / 09,
Job Site Address: 76 L t ,d z, S T City/State/Zip: TAIGA 14b-.1
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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 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
Investigations of the DIA for insurance coverage verification.
l do hereby certify
/under the pains and peennallliiees of perjury that the information provided above is true and correct.
Si4natttre: i�e.L-dTsir_ 1I�//L,�g.L/J—tl'� Date
Phone# gel- 5—�,? — yezl
Official use only. Do not write in this area, to be completed by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/'town 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, MGL 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 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 fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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 filled 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. a dog license or permit to burn 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
2evised•5-26-OS
Fax# 617-727-7749
www.mass.gov/dia
-� CITY OF SALEM
PUBLIC PROPRERTY
WDEPARTMENT
VPA91I�t�:ON S.Rc£T • S:1Li01, S1AiiACilt ,l:l ii D: 1:
17FI:978J454595 • F.%X:978-74C-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR 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 MGL c
111, S 150A.
The debris will be transported by:
(name of haular
The debris will be disposed of in
._ lur�facility) _
t Jddras, aI Iai:;,i'o _
a r_.l�Il�l. QI 'i all It 1(:�].ICJlI
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The Commonwealth of Massachusetts
FOR
Board of Building Regulations and Standards MUNICIPALITY\� Massachusetts State Building Code. 780 CMR, 7" edition USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Jammu)
One-or Tteo-Family Dwelling ! 2W8
This Section For Official Use Only
Building Permit NugCommmiumed
Date Applied:
Signature: Bang Inspector of Buildings Dale
SECTION l: SITE INFORMATION
1.1 Property Addrgss 1.2 Assessors Map & Parcel Numbers
�\\ l.la Is this an accepted street'?yes ✓ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system
❑
Public❑ Private❑ al Check if yes❑ p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco
L/hdan S 't'
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': .S d en v !71
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
Standard City/Town Applic• tion Fee
2. Electrical $ ❑Total Project Cost(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: �7� d ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) G5 6.20S4, 7111911d
,9d D 4)lC �jZ�-},/IW/ems License Number Expiration Date
Name of CSL- Holder
List CSL Type(see below)
Address T Description
s
U Unrestricted(up to 35,000 Cu. Ft.l
R Restricted I&2 Family Dwelling
Signature '/ M Mason Only
90 .7S?y� `� G/ RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re 1st4red yyome Im vement C ntrac�or(HIC)
�he�d� p 9�f^ t rtS /3 -9r//
HIC Company Name or HIC Registrant Name Registration Number
Address /O C /---yA� _ / 9Zi9/D
pv /Ji m ')k/ "'.sy-'yU Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Cl No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
/ / SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, �h tAi)1 o L_, r I k43-6 , as Owner or uthor_Aaen hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. /
O r7GLG 7LA'� /
Print Name
Signature of Owner or Authorized Agent - Date
(Signed under the pains and penalties of t a
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics.decks or porch)
\ Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches_
Type of cooling system Enclosed Open
3. "total Project Square Footage"may be substituted for"Total Project Cost"