60-62 PERKINS ST - BUILDING INSPECTION (2) /-��� CITY OF SALEM
���� ����� PUBLIC PROPRERTY
���r' DEPARTMENT
;:I\IR::R[liY UNIK:ULL
. �4.�v<ae l?CWnsHincroxS'rxeel'�S.�t.e.a.M:�ssncinrv;.r.rsGl979
'ft:l_97&74i9i95 �Fnx:97M-7i�)S3G
Workera' Compensation Insurance Affidavit: 13uilders/Contractors/Electricians/Plumbers
A � licant tnformation Piease Print Le iblv
V:IR10 (Buciinss/OrganizatioNlnJividual): �nG. ( ��` �vN� �� IV" 1
Addre�s: 1 \ ��-Z� ��
Ciry;Stacc;7ip����( M� O« t s Phone N: I� O uSz / �� /
Are �ou an employer? Check the uppropriute box: '1'ype�rf project(required):
I 1.�1 am a cm lu u with 4. Q I am a gcncral contractor and 1 �
p Y' 6. ❑ h`ew construction
employces(full�encllor part-anta).' havc hircd thc sub-cuntractors
� listtd un the attached shcct. � �• ❑ Remodeling
_.❑ 1 am;�sole propriccor or paMcr-
ship and have no employcus These sub-convacrors have 8. �emolioon
working f'or me in uny capacity. worAers' coinp. insumnce. 9. 6uilding addition
�Ko workcrs'comp. insurnnce 5. � We are a coiporation;uid its
rcyuireJ.) officers have esercised their 10.Q Electrical repairs or additions
3.0 I mn a homeowner Juing nll work right of zxemption per MGL 11.Q Plumbing rcpairs or additions
myself.(No w,orkers' comp. c. 152, y l(4),and we have no �2.0 Ruuf'mpairs
insurancc reyuired.J � cmployec.. [No worktrs' �3.0 Uther
comp. insurancc mquircd.]
•nny�pplicant tl�a�chccks box/II musr also lill um�he xniun IH:luw showinp ihoir wurk�rri cumpenvtimi pulicy inCnrrtuiiun
' ilomeuwrcn whu submil lhis a�Ydavi[indica�ing Ihey arc doing ull work anA thcn Aire outside ewurxton musl aul+mil a new al'fJavil indiuling mch.
�Comncmrs ihai chcck this box munt a�txh�d nn addilionul xhut shnwing tht namc of thc sub-controqurs and�heic a�urkcrs'cwnp.�u�li<y informadun.
/am un einpluyrr thut Is providing rvurkers'compensnpon iiuumnce jur�ny einp/ayees. Belnw is the pa/icy aud job sile
i„jo�murion. n ,,,, np
(nsuranceCompany Vame: ��G�,�`� ��U�w Y\` `
Policy:i ur SelGins. Lic. ti: _.--...--..---.— Expirauon Dace:
Job 5icc qd�lress: �`62 ��.1�5 S� CIlY/Sl'JLUZIp:�_Y`-C.]IM'' ' Il'V d�� /�
.�ttach a copy af tl�e workers' cumpens•rtion policy declar•rlion page(showin�the policy number rnd expiracion d•r[e).
1'ailurc w sccure coverage as requireJ under Sedion 25A uC�IGL c. 152 cau lead to che imposicion of criminal penalties of a
tin� ap to SI,SOOAO�nd/or ono-year imprisonment,ah�acll us civil �nallics in thm f'orm uf a STOP WURK ORDER and a fine
of up ro 5250.00 a day against the violaeor. 13e adviscd th�t a copy uf d�is stalement may be lurwarded m �he U17ice uf
lu<�esiigations al'thc DIA for iniw'arct eovcragc vcri[ieation.
!do herchy cer�ijy��nJe�d�e pain�s und pertulties uf prrjury tha!tTie infunnulronQruvida�(ubove is�rae m+J correct. �
Sie:i;uure: v Y VKIVY� ��Jv�"Li�e'/ 1)�tc� � I � O ���
Phurc:7:
OJJiciu!tu'e m+ly. no nnt rvrite iu dtis ureu,tu be cuu+plrleJ by ciry or to�vrt ofJiciu/.
Cify or'I'r��rn: _ _.___.__ Pcrmitll.iccnse#_____ _
Issuing Aulhurily (circle onc):
I. Bu�rd uC IlcaliL 2. 13uildine Dcpurhnent J.Cil�'/fo���n Clcrk 4. �lectrical [nspccfor 5. Plumbing lnspcctor
6. Olher
Cunlnc� Pcrson: ...___ Phonc #:
Information and Instructions
� .. _ .
p4assachu;etu Grneral Laws chapcar l i2 reyuires ull amployzrs to provide workers' compensation tix their emplayees.
Pia,usne to this siutute,an rmpluyre is defined as"...every person in tht service uf another under any contract of hire,
axpress or implicd,oral or writian." �
:1n e�eployer is dctincd as"an individual,p•rrtnership,associauon,corporation or other legal enrity, or any two or more
of thc foreguing angaged in a joint entzlprise,:u�d including the legal representacives of a deceaseJ employer,or[he
rocaiver or austee of:+n iudividual,pwenership,associati�u or oeher]egal zntity,employing employees. Howevcr the
owner of a dwelling house having not more tl�an chree apartrnents and who resides therein,or the occupant of the
Jwelling house of another who employs persons to do maintenunce,construction or repair work on such Jwelling house
or on rhe gruunds or building appuctenant thereto shall no[because of such employment be deemed to be an emploync"
MGL chapeer 152, ��'25C(6)also sta[es[tm["every state or local licensing agency shall w•it4hold the issuance or
renewul of e liccnse or permit to operate a business or to cons[ruct buildings in the commonwealt6 for auy
applicant who hns not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL ctwpmr I S?, 325C(7)states"Neither the conunonwcalth not any of its political subdivisions shall
zncer in[o any cuntract fo¢�the perfomiance ofpublic work until acccp[able evidence ufcumpliance wich Ihe insurance
requirements of this chapter have 6een presented to the contracti»g authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes[hat apply to your siWation and,if
necesssry, supply sub-contraeror(s)name(s),address(es)and phone nwnber(s) along with their certificate(s)of
insurance. Limiczd Liabiliry Companies(LLC)or Limiced Liabiliry Partnerships(LLP)with no employees other than the
members or partnnrs, are not required to carry workers' compensa[ion insurance. Tf an LLC or LLP does have
croployees,a policy is required. Be advised that this aff'idavit may be submittzd to the Departrnent of Industrial
Accidtnts for confimtation of insurance coverage. Also be sure to sign und d•r[e Ihe uftidaviL Tli�aF'tidavit should
be retumed to the city or town that the applicauon for the pennit or license is being requested, not[he Department of
lndustriul AcciJen�s. Should you have ;my yuostions regarding che law or if you �ro mquired to obtain u workers'
compensation policy,please call the Depaztrnent at[he number listed below. Self-insured companies should enter their
tielf-insurance license number on the appropriate line.
City or Town Offlctals
Please bc sure Iha[the affidavit is complete and printed legibly. The Department has provided a sp•rca u[the buttom
of dia uffidavit for you to till out in the event the Office oi Investigations has to contact you rzgarding the applicanc.
Please be sure to till in the ponniUlicense number which will be used as s retierence nwnbec [n addition,an applicant
tha[must submit multiple permidlicense applications in any given year,need only submit one xffidavit indicating current
poiicy intormation (iinecessary) and under'7ob Site Address"�he applicant should write"all locueions in (city or
town)."A cupy of the affidavit that hss been officially stampeJ or marked by tht city or town may be provided to[he
applicunt as proof ehat a valid affid�vit is on file for futura permi4i or licenses. A new at7idavit must be tilled out zach
yzar. Where a homt owner or citizen is obtaining a licenx or pzrmit not related ro any business or commercial venture
i i.a. a dug license or permit to burn leavts etcJ said person is VOT required to complete this affidavit.
�t'hc Oflicc of(nvesei�a[ions a�ould Iike w rhank you in adveince for your cooper�[ion and should yuu have :u�y yuastions,
plaast do not hesicate to give us u call.
fhe Deparnnnnt's adctress, telephune and fax numbar:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investlgallons
600 Washington Street
Boston, MA 021 l I
Tel. tl 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
ac����d s-�r,-os www.mass.gov/dia
. .�'�` � CIT'Y OF SALEM
3 � � i PUBLIC PROPRERTY
�:,,�, DEPART\�1ENT
.,�::�h��, � �;,,:,,«.
�t.�",K I2C Vf�.�it u�i.:JuS:REET �$.iLl'\t, 1ta�i.u::u ;�i ii�;»C
Tet:y78-7�i•1i95 � F.��c:978•7iG98�6
Construction Debris Disposal Aftidavit
(reyuired fur all dtmulition aud rznovation work)
In accordunce with tha sirch edicion of[he State Building Code, 730 Ch1R section l l 1.5
D�bris, and the provisions of\�iGL c 40, S 54;
Building Permit # _ ._ __ is issued with the conditiva that the debris resuldng &om
this wurk shall be disposed of in a proprrly licensed waste disposal facility as dzfinc� by V1GL c
l 11, S 1.SOA.
The debris wili be tr�nsported by:
�eL� �v� �ou�o� ��� )� �,�U
��nz�itr�
flle�lcbris will be disposed of in :
�ue� ���1�� 5�l�� �r�
(u�meof aciliry)
- I i c� ��a��n� R� �u��r� /'��
iud.trc,+ ot' ac:L(y)
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PUBLIC PROPERTY
DEP21R'I14IE►�iT
�uo►Fusr o.��-•v� `
Mwraa
1�W'��'�l��T���4 W�a�tst�-�s 01970
14L•973�7ii959S�FNc 97L7�9�
APPLICATION FOR THE REpAIR RENOVATION CONSTRUCTION
DEHOLITION, OR CAANGE OF USE OR OCCUpAN�y FOR ANY EXISTINCj
STRiTCTL�it OR BUILDIN
. 1.0 SITE INFORMATION � " • �
Location Nams: 60 r �S l7�' Building:
- - -
Addresx- - -- - U����- 3 -
P'°p°'e�' 60- 6z ���<l�s �
Property Is bcatsd in a;ConeervaUon Area Y/N Histaric Dlatrld Y/N
Z.0 OWNERSHIP INFORMATION �
3.1 Ownar ot LandEb P�fkrL.S ��Pc�.Q �2 Usf-
Nams: 3r�
'�fe": ►� 2eZZ� R
eve�l r`r
re�eprwne: 97q gSZ y9d�-
3.0 COMPLETE THIS SECTION FaR WORK IN FYiQT�Nn BUILDING9 ONLY
Addition ExisGng
Renovation Number of Stories Renovated
Change in Use � N�
Demotitlon ,/ Existing
Approximate year ot Area per flaor (s� Renovated
construction or renovation ZOU�-
of existing building New
Rryp/ Description of Proposed Work: �x��d (� ek�STm� ��}-►1gi� �p
I h C( uo�St Ck�r c� (�oJ t�v, I"1 Q�., �JFd`aa� �Y CIoS-e�' S�a,�-�,
--- Mail Pennit to: ---
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�_ w ,�n •
C�'N'1
j
�f�)l.�'l�t���
' What is the curtent use of the�ui�di�9T
�
Materisl of BuildingT �0� N dweiling.how�many unita�b<, , , .
�U t h s Buildi n g Conform to Law? �'�5 -
Asbestos?
p�rchitecCa Nams � �
Addreas and Phone ( 1
Mechanb's Nams i ��
Addreas and Phons �a ��"�-z�+ �a ��" �
c«►aw�+ s�v��u���# c�`iS�'1 b HIC Registration N 1� 60 9 S
Projed S U PertnR Fe�Cakwlatfon I
Estimated � Esdmated Cost X i71S1000 Reaidentisl
pertnit Fes �5 ` �
- -----... --_ - __ .. _ ___. _ - EsUmated Cost X 511lS1000 Gornmeroia4----- - - I
--� � M Additional 55.00 Is added as an
r� Adminiatrativs charge. ,
,
r �
� �� Make suro that alt flelds are Properhl and legiby written to avoid delays in procesaing. �
` The undersigned doee hereby aPPly for a Buildinp Pertnit to b�e abovSC��
X / �
specificaUons. Signed under penatty oi perjury
I.(iCJ
Date � �� �
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