22-24 PARK ST - BUILDING INSPECTION CITY OF SALEM
r' PUBLIC PROPRERTY
. .�r DEPARTMENT
�;ulmiu.r.rnlusu.+Il.
M.AyoR 120 WAiI IING'I I IN S 1 KFE I' a S.ALIC�i, AfU5AC1it. t i iI 31970
111: 978-745-9595 ♦ F,X: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ulicant Information Please Print Legibly
Name (Biisinc>s,OrganisttiuNlndividual) �/
Address: P. 6-0X 174
City/State/Zip: 24! , &tGrOA,/ //D. Phone At:
:\re vo an employer? Check the appropriate box: Type of project(required):
1. I am a employer with w /_/0 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors 7 ❑ Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet. I
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' cum insurance 5. ❑ We are a corporation and its
[ p� 10.❑ Electrical repairs or additions
required.] officers have exercised their ,
right of exemption per MGL 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t I lomeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
�Cuntracrors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
infonuution. !"Jn
Insurance Company Name: /IG�
Policy #or Self-ins. Lie. #: 0 Q$�c 2://!9�0 Expiration Date: f eo�Alineq y9
Job Site Address: ��a� P�ie/C 7T. 7i.IL61�J City/State/Zip:,�1�L�
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
tine 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 $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 coverage verification.
/du hereby certi nd theTains r pen to of perjury that the information provided above is true and correct
Swnattlre: Dale'
Phone,n #
Official use only. Do not write in this area, to be completed by city or town official
Citv 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 ettjployees.
Pursuant to this statute, an emplt tyee is defined as "._every person in the service of another under any contract of hire, ,,.
express or implied, oral or written."
An enrph�yer is LICtined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the lorcgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
1'ecei\'er 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."
%IGL 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, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforniance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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 till 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 bum leaves etc.) said person is NOT required to complete this affidavit.
'File 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
Ofilce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
} r DEPARTMENT
N.11'VH 12, W.\sl IINI;I ON S I RLr:r • S�11\1. )1 uS.1,:tu ar:I 1 G J 197�
-Il.l.: 978.74;');9; • FAN: 978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n qn Please Print Legibly
Nanic03usule- Organization lndir idual,)Q UIGQ�J1lG oG�" ,
Address: do x 174
City/'State/Zip: �frk�/NrTOI�/ /�� Phone #: /-82i/ Jl3lo
\re yo an employer? Check the appropriate box: Type of project(required):
I. I ❑m a employer with R/ /I49 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time)." have hired the sub-contractors ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. 7.
These sub-contractors have 8. ❑ Demolition
ship and have no employees
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
3.❑ 1 am a homeowner doing all work g P
right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant that checks box HI must also till 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 must submit a new affidavit indicating such.
lContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A
Policy #or Self-ins. Lie. 9
#: 0 7f�� �O / Expiration Date: ddAl 7 w
Job Site Address: oV—.,24 0WeX ST 7tIL6/% City/State/Zip:,�l%LT n�0�970
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 certi ' ld the pains i pen to of perjury dint the information provided above is true and correct.
Sigmature: Q Date:
Phone 4 $`G!` �f56
Ofjicial use only. Do not write in this area, to be completed by city or town ofjiciat
City or Town: Permit/License #
Issuing Authority (circle one):
t. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persom Phone #:
C rry' OI-,
Puii c PROPI:R'1'l"
+ f ICI-:P_\K"1 \If.N'1
APPLICATIO�MR PLAN EXAMINA'f[ON ANU I3UILUING PERbII'[ALL STRUS EXCEPT I AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must complete all items on this page
SITE INFORMATION
Location Name 'T//E evvT' Building
Property Address A3=-14 &RK ' T.
Map#
Located in: Conservation Area Y/N Historic district Y/N
Use Groups
(check one)
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel R1 _
(check one) Assembly (churches) Al
New Building_ Assembly (nightclubs etc) A2_
Addition Assembly(restaurants. recreation) A3
Alteration Business B
Repair/Replacement Educational E
Demolition_ Factory (moderate hazard) F1
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H
Accessory Building Institutional (residential care) I1
Other(describe) Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile M
Storage(moderate hazard) sl _
Storage(low hazard) S2_
OWNERSHIP INFORMATION(Please type or Print Clearly) �1 t
OWNER Name P16H,002o IIiPOGL/k0�12•
Address t rl^ecl 19"V.,C—- Am Ca/ D h'✓1.
Telephone (017— 4,&,; —+;e,.?
DESCRu'•rR)N OF NVORK TO BE PERFOR:INIED Ow. 97) R. Pr2A66T
ON /Roo
ESTIMATED CONSTRUCTION
CONTRACTOR INFORMATION
Name �YOitL�irlDl�6�IldO
Address OO136]C /7¢ �6Y//eG7a/�,f1�•
Telephone 72'/-9Coo/ !!36
ConsU'uction Supervisor's Lic #
Home Improvement Contractor#
ARCIIITEUPENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $,�7�(/$1,000 + $5.00 = "r
Commercial est. cost x $JOS1,000 + $5.00=�
coMNtF:Nrti 1I Otl, _ t�.cdray��icr,
&,-� 9942 Ga t�Fc2 I lliTfi 6�/�,00
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signea�-�
Date 3 z% ors
q ti
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