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(97 - - Ol
(OR) CELL NUMBERS * 978-223-77401 *978-42345741* 781-gAl-2337
�� CITY OF SALEM
PUBLIC PROPRERTY
� X
DEPARTMENT
sIM RIEY DRIK:011
VIAY(M Ir.VASla.VGT0N STRFa;'T 4 SAIEM,MAanU n.�Frts 019TJ
ThL-978.745.9595 a FAX:9M740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information ^ / Please Print Legibly
NaMe tHuaim:WOrgmizatioNlndividLW): (/r ,V
Address: .1a P&L4 5442�
Cit /Srarcizi . � Phone 2�— 7 " O y p d�'�/� /i.
An you an em to er? Cheek theappropriate box: .
I� YType of project(required).
1.0 1 • cmploycr with 4. 0 1 am a general contactor and 1 6. 0 new construction
Mployevs(full and/or part-tine).• have hired the sub-contractors
71
1 am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity, workers' comp, insurance. g, 0 Building addition
INo workers'comp. insurance 5. 0 We are a corporation and its !0.❑ Electrical repairs or additions
re uircd officers have exercisdxl their
i 9 )
3.0 1 am a homeowner doingall work right of exemption r MOL I LO Plumbing repairs or additions
P Pc g Pa
myself.[No workers'comp. c. 152,§t(4),and we have no 12.0 Roof repairs
insurance required.] t :mployccs. [No workers' 13.❑ Other�Y��� ?o�oy
comp. insurance rcquired.J
.
Any applicant nun cheeks Jim#1 must also Jill can the secliun hclow Stowing Ilarir wurkeas'cumpanualun policy anion a jot,
'l lomv+rwnen who submit this affidavit indicating they am doing all work and then him onside eemtmetoa mail•uhmij a new arrdavit indicating mach.
:C Condors that check this bore must attached an additional Jim showing the name of the rub-contraeton and their Wuhan'comp.policy infamutiva.
lam un crttplayer that Lr providing workers'compentaton insurance fur trty employees. Below is the pis/icy and Job site
information.
Insurance Company dome:
Policy is or SclGins. Lic. #: ._..-. ._. ._.._ Expiration Date:
i
Job Site Address: City/State/Zip:
4 Artuch a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required undcr Section 25A of.`iIGL c. 152 can lead to the imposition of criminal penalties of a
ti nc 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 5250.00 a day aguinst the violator. lie advised that a copy of this statement maybe forwarded to the Office of
Invcan�atiuns ol'thc DIA for insurance coverage verification.
l do hereby certij under the pis" s and pe lies of perjury lAat the information provided above :r true ar correct
tii :cnurc: [)are-
Ph,
••:7
O)TIciu use tally. Do not write in fitir area,to be completed by city or town official
City or Town:
Issuing Aulhurily (circle one):
1. Iivard of llcalfh 2. Building Department 3.Cityrfo%in Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ _ Phone #:
Information and Instructions ;
r%4assachusetts 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."
;Vt employer is defined as"au 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,patmership,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."
hiGL chapter 152. §25C(6)also states that"every state or local licensing agency shag 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 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)mame(s),addresses)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 Official,
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 pormit/license number which will be used as a reference number. In addition,an applicant
that must subunit 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'ho Obis of Investigations would like to thank you in advance fur 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
OfAee of Inveadgedons
600 Washington Street
Boston, MA 02111
Tel. #617-727-49M ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dla
CITY OF SALEM
Q' � PUBLIC PROPRERTY
DEPARTMENT
MY:''NL9.01 L
A%lon 12C W.\9 Ru::OMS BEET•!.tt. %I.%t.\VYU:: t.t 11a%9r.
To:976.7454M •E•mx:OMAC.964
Construction Debris Disposat Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.3
Debris,and the provisions of viGL c 40, S 54,
Building{ Permit N _ . ._ 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%AGL c
111. S 150A.
The debris will be transported by:
— — (llama of±hauldr)
medcbris will be disposed of in :
Name oY fa.�Lty)
L
AI
En-y Ogg
PUBLIC PROPERTY
DEPARTME►1iT
Al.%mWJUAN o•rc,•,v L
MAroa 130 WASH9N .Tnw STRW•
S.ubY,.VASA01LShll3 01970
14L M743.9S"9 PAZ M740-96%
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY FMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 30 Building: / — a
5f'lei
Property is located In a;Conservation Area YN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owaw.of Land �o
Name: a AG z 4 - v S�`
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN E7IISIli14p 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
Bdef Description of Proposed Work:
--------Mail Permit to: - - --- - --
What is the current use of the Building?ai of Building? -
(ti/acy� If dwelling.how many units?
Materi z- -
WiU the Building Conform to Law?
Asbestos? Ala
Architect's Narm
Address and Phone t )
Mechanic's Name
Address and Phone
Construction Supervisors License 0 HIC Registration p
Estimated Coat of Project S lD�' ` Parrott Fee Cakxiletion
Permit Fee S S '— Estimated Cost X$7/$1000 Residential
Estimated Cost X$1141000Comrnsrc►at
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 Permit to'build to th bove stated
specifications. Signed under penally of perjury
X �-
Date-
Q
PC
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0
0
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3
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y
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-- 96