50 PICKMAN RD - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
SaUa FY U ti-CoLL
M.trd nt Ir.WAstw%c raN STREb'r 4 SAtFw.MASsAci fu.wris 0197V
TLL-979-745.9595 a FAX:9M74L%9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Leeibly
NametBucitw.wO%anizatioNlndividuall: --r�O a-L C L4 k_�6AJ
Address: /x t (A) ®o h Ln ta' ICJ S
CiI .SaeiZiP Lv w 4 w" Ol° p { h one /: � r / �� 3 3 9 tZ
Are you an employer?Check the appropriate box: 'type of project(required):
1. I ant a employer with 4. 0 1 am a general contractor and 1 6. 0 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 : ?• ($Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp, insurance. q. Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its 10. Electrical repairs or additions
required] officers have exercised their
3.0 1 ant 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 12.0 Ruofrepairs
insurance required.] t employees. [No workers'
13.❑ Other
comp. insuran
ce required-]
P
•Any applicant thin cheeks has el must also rill out the Mellon iwlow thowing their wurktas'compensation policy infnrmatiun
'I loinco rter who submit this affidavit indicating they ate doing oil work and then him outside coal Ilona moot bubmit a new affidavit indlattins such.
-C,muml or,that check this bat mart attached an addidis el sheen%hawing the name of the sub-comractom and their worker'comp.policy information.
/am an employer that Cr providing workers'compensation insarance for ray employees. Below is the policy and job site
informarime.
Insurance Company Name:
Policy#or Sclf--ins. Lic.i1: _._ . . .____ Expiration Date:
Job Site Address: City/Slate/zip:
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
find 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. Ile advised that a copy of this statement may be forwarded to the Office of
luvcattgatiuns ul'the DIA for insurance coverage verification.
l do hereby certify under the pains unit penuhies aj-perjjuryy that
�the information provided above is true and correct
1i t It tr 9-il+.�x}_eJ 1-F.tC�t-lf D.atc F 1 -3 b t7
, , y.
f)iricial use only. Do not wrire in this area,to be caatpleted by city of town ojj/riaz
City or Town: Permit/License
Issuing Authority (circle one):
1. Iluard of Ilealih 2. Building Department 3.Citylfown 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 employee&
pursuant to this statute,an emplowre is defined as"...every person in the service of another under any contract of hite,
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 Cho 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the botwm.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
(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 permitilicense 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 bum leaves etc.)said person is NOT required to complete this affidavit.
1'hc Otiiae 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
O®es of lnvestiptlons-. •-
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.niass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I_,
C W.\91N::JN51tEET•1\U M. .1.\Ci\t::u a.i 15;,:9IC
Tttt:97f o-im a F.\x:OMAC-9846
Construction Debris Disposal Affidavit
(required for all demolition alul renovation work)
in accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions of M. GL c 40,S 54;
Building Permit N - . _ is issued with the condition that the debris resulting from
this work shalt be disposed of in a properly licensed waste disposal facility as defined by vlGL c
111. S 1.50A.
,
` The debris will be transported by:
I 6
— — wama of hauler)
f
{
fhc debris will be disposed of in
(nJme uY Iatillty)
II`
l .lt.
I� O � S � ax8 P 'r 16, 0c
I
I
�t ua PT
� I
I.
I i
i
I
i
i
I
I ,
I i
i
d �
J'ois� L\.awgc-n-S
Ccic ,` 5 Aa16 A S EX (LlK) 4
roo I IJJc�S ' Fk rLEAbY Exe(s4-(w9 .
EIT�tOF
�. PUBLIC PROPERTY
DEPAR"TNIENT
YJ%OWJLSV ORKT) L
1/AVM 130 WAunrwTm 5n iar•
mat; a:skrs 01970
TV2--97g-74i9595•FAX;IM7404M
APPLICATION FOR THE REPAIR. RENOVA77 N CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCirp�rtry FOR ANY EXISTING
STRUCTURE OR BUII.DING
O SITE INFORMATION
Location Name: Buildln¢
-
U jclL i /08 6076
Properly is l0c2W In e:Conssftvdm Area YIN HkW tc District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of land
Name: /hp. Cvfz-h n
Address:
3-0 P1c le-kwJtL 1> VVL A IF, rH,
Telephone: `7 �F O 9 S
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIINIi BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year Of Area per floor(sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
fLfy � IriCE Ck15�r�S �oWC �< c� Eck
-- -- -- Mail Permit to: .fo P c Ic N, , (L S /F k. _(L±& 0 1 �0 -
What is the current use of the Building? Fr G I
Material of Building? �
o n n - If dwelling,how many units? ± -
Will the Building Conform to law? Asbestos? a 5a o
Archileces Name
Address and Phone ( )
Mechanies Name •-r^ -, 1
� � t �o �, ol I.ra� � a � � , s� 33� Qy
Address and Phone
Construction Supervisor License S [' K y 9 17 '/ HIC RegIStratlon a
Estimated Cost a Project 3 a 7 D o . Permit Fes Calculation
Penns Fee f D� Estimated Cost i7Is1K1 10 ResidUal on
Estimated Cost X$11/:1000 CommwclaL
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building�P[ermit to build to the above stated
specifications. Signed under penalty of perjury
Date R - 1 3 -o 7
^ "I
N
a S `d
z�
e• Ci � 96