9 PIONEER CIR - BPA-08-106 REROOF CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
;iU%I1WKTXY DkISCOLL
MAYOR 120 WASHING'ION$'rRrLT 4,SALrat,MASSACnuslsrISO 197^.
Tta.:978-74.5-9595 •FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(BusinessiorganizatioNlndividual):
Address:
City'StateiL.ip: Phone 1':
Are you an employer? Check the appropriate box: 'Type of project(retuired):
1 1 am a employer with�_ A. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors 7. ❑ Remodeling
2.[3 1 an,a sole proprietor or partner-
listed on the attached sheet. :
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 it corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
ri ht of exem tion e P'r MGL I LE] Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work S P
myself. [No workers' comp. c. 152, y 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 01 must also till out the section W,ow showing their workeri compensation policy infnrrtmtion.
'l(nmet).ne s who submit this affidavit indicating they arc doing all work and then him outside contractors most submit a new affidavit indicating such.
�Contracton that check this box must attachdd on additional sh v:t showing the name of the subcontractors and their workers'comp.policy information.
!our air employer that is providing workers'compensation iusuranee for my employees. Below is the pu/icy and job.site
information. I
Insurance Company Name: �.. __.__...__
Policy a or Self-ins. Lie.#: .—._.___..._......___—_— Expiration Date:
(�
p� c
Job Site Address: \ `i ,� 'C'e_R_Y �\{^ City/State/Zip:s&I,
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 NIGL 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. Be advised that a copy of this statement may be forwarded to the Office of
luvestigations ol'the DIA for insurance coverage verification.
1 do hereby certify undeer the pains and penalties ufperjury that the information provided above is true and correct.
Sienala e Yh Uatc'
Phone 7:
Official rise only. Do not write in this area,to be completed by city or town official.
City or'Posrn: - ------._---- Permit/License --.---_—
Issuing Authurity(circle one):
1. Board of Health 2. Building Department 3.Cily/Totan Clerk 4. Electrical Inspector 5, Plumbing Inspector
6.Other —_—
Contact Person: Phone#:
Information and Instructions ry
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emphgyee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
:1n 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."
N1GL 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,lvlGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomiance 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 till 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 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. it dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
'['he Office of Investigations would like to thank you in advance for your cooperation and should you have;my 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
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.\YiN I2C W.\.91tNl::0NS;BEET •S.\LFN, St.4C3AQiL 9s115::9JC
TO:9711-745� 595 • FAX: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, 730 CNIR section 111.5
Debris, and the provisions of v1GL c 40. S 54;
Building Permit # _ _ __ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by .1GL c
l 11. S 1.50A.
The debris will be transported by:
o �S,
— — (name cif lwular)<
Hic debris will be disposed of in
(came of facility)
_— iml.:ros, of the Lryl ._ n. ..
.�g,:a�a oi,�cnr.u.pp.ivat
GITY-OFS
PUBLIC PROPERTY
DEPARTNI&NT
wi�OfFJt.6Y o•�••,w
MAYOR
APPLICATION FOR THE REPAIR. RENOYATI N CONSTRUCTION
OCCUPA
D_EVIOLITION. OR CAANGE OF USE R NCY. FOR ANY EXISTING
STRUCTM OR BIL"
1.0 SITE INFORMATION "
Location Name: Building
__.... Property Address:
Property Is located in a:ConeervsdOn Ares YfN Historic DlstAot Yfl®
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 0\
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of
Y Area per floor(sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: -
�r
,cam.` b
-- — — Mail Permit to: G --
What is the current use of the Building? if dwelling.how many units?
Material of Building? c� Asbestos?
WiM the Building
Conform to Law? �
ArchitecCs Name ( 1
Address and Phone
Mechanids Name o f
Address and Phone �D
Constnmdion Supervi
sors License N HIC Registration 0
Estimated Cost of Projed i � Pennil Fee Cak elation
Permit Fee i Estimated Cost X$71:1000 Residential
- _ Estimated Cost X V 1151000 Commercial--
An Additional$5.00 is added as an
Administrative 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 the above stated
speciftatkms. Signed under penalty of perjury ---
Date
A a
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