8 PETER RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\LUiN I1C W.\iINXt::JN S.'REET •SALI'V, %WC
TFI:9M743.9595 •F.%-X:978.74C-9846
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Construction Debris Disposal Affidavit
(required for all demolition alul renovation work)
In accordance with the sixth edition of the State Building Code, 780 CA1R section 111.5
Debris, and the provisions of MGL a 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 1.50A.
The debris will be transported by:
Iname of hauler)
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fhe debris will be disposed of in
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111.afi1C JC IaJ II ICY)
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.applicant Information D Please Print Leeibly
Name tau<incWorganirationtlndividwi): V� � � �U�C
Address: -706 i55sek, S . J'
Citylsmteizip: LCtM- 1114 Phone
Are an employer? Check the appropriate box: 'type of project(required):
I.1_fT I am a employer with_ 4 4. [1 1 am a general contractor and 1 6. ❑ New construction
employees(full andfur part-tine).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp, insurance. g, ❑ Building addition
,No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have cxcrctwxl their
10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers comp. c. 152,§I(4),and we have no 12.❑ Ruof repairs
insurance required.] t employees. [No workers' 13.❑ Other /
comp. insurance required.]
-Any applicant rem checks boa nl must also tilt out arc sectian b:luw dtowing tlatir wurk='cumpenautiwi puliuy infolawoo ,
' Ilom,ntwnen who submit this affidavit indicating they arc doing all work and then hit,collide contmctant must submit a new affidavit indicating s.ich.
Cwuttxvra that cbssht this box must attached an additional shot showing the more of the sub-contraetws and their workan'comp.policy information.
I urn all employer that kr providing workers'contpensadon insurance for trey employees Below is the policy and job site
information.
Insurance Company Name: ITA V
y V/S 7,',77 l{t7 0- O-CExpirationC tfi Folic N or Self--ins. Lic.ti: /�� . . .-_-_ Date:
Job Site Address: 4 rl City/State/zip: xkl1,
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.IGL 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
hivcmigasioas ufthc DIA for insurance coverage verification.
l den hereby certij alder the pal s and penalliev ujperjmry that the injarmadon provided is It a mild correct
tii C:runref M� 7-�wnMt�, Date' CY 1,
P tti•;c / 1 S !� r7232—
Official use only. Do not write in this area,to be completed by city or town ay]IL.&L
City or 'town: Permit/License p
Issuing Authority (circle one):
1. Iluard of Ilealth 2. Building Department J. City/Coon Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Ct,nlaet Person: -- Phone p:
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Information and Instructions
1%lassachuseus 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 eolployer is defined as"tut individual,partnership,association.corporation or other legal entity,of any two or more
Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver nr trustee Ot am individual,partmerahip,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 w ith 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 an 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.
I'lease 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/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 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.. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l"he Otlicc 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
offlee of Investipdons
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/dia
/00 EITY-OFN -- -
PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR THE REPAIR. RENOVATI N CONSTRUCTION,
DEMOLITION.OR CHANGE OF USE OR OCCUPwxr F. FOR ANY EXISTING
STRUCTURE OR HUILDDLG
TO SITE INFORMATION
Location Name: Building:
- -
property Address:_..-
Property Is located In a:Conservation Area YIN Historic Dhtrict YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 17
Address: g 7i S/n�rzl-q w o L jU
Telephone: _
3.0 COMPLETE THIS SECTION FOR WORK IN EK TM 13UILDINOS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
iN✓t L ��i( � IV >1
-- --- _---Mail Permit to:
What is the current use of the Building?
Material of Building? It dwelling.tow many units?
Wiil the Building Conform to law? Asbestos?
Architect's Name
Address and Phone )
t„leohanies Name
Address and Plane
Construction Supervisors License 0 HIC Registration ft lz�d6�
Estimated Cost Project$ 2 O Permit Fee Calailatlon
i Estimated Cost X s7/51000 Residential
Permit Fee
- - — - Estimated Cost X S41/i1000 Canmerclal- - -
An Additional $5.00 is added as an
Administrable charge.
Make sure that all flelds are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to th hove stated
specifications. Signed under penally of Perjury
Date /
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06
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