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11 PRESCOTT ST - BUILDING INSPECTION (3) �a'1C1L�L to P"I loowd In dto I WAM OMb PUPOV tau"In dot� ;� MpnuolMlr111Alod BULOq POWAT PIMA UK pdO MM 0M Off) �cd 1DO� T, PuASB PLLCUT LMMV a CMMXMV ToAVCO NLAVO w r110Cmsm TOTMRWWMOFWLDML 7 M www000 hwf► aPPWs for • Po" b buMd �000�dinp >o qM torawirp woofte"M owMrawa�. hr;5� en� ia� e; S �w�Prnan. AM �'A Nd�xi Nwn� D©a a a Ad*M& PhM 1112- Xn ram. Mw &NOM No= Atr 1+i a AddOW& PIWM YI�III Y/l0 per d wt idw u r ' v , I - whMO d wt el wow M" —.a---- vM MI OWN=to"I o00 a�,uo.�.• N " No UM"0 c o as `- X a E'�V7�5- n p�u�nK P� OF PMLWV 11 ,oh o r I VA , �e��Jw�ior\ MAIL PERkVT n I �o �� 1�oone r" t • APPLICATWN FOR Pen"To LOCAMN !� PEF"TORAMM NrBP OF 6lJ�DMgg I> The Commonwealth of Massachusetts ;. Department of Industrial Accidents OJj'lce oflnvestigadons 600 Washington Street Boston,MA 02111 www.massgov/dla Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriaans/Plumbers Applicant Information Please Print Lenibly Name (BusmecslOr niaation/lndividnai): �r n 0 Cons �rL d;OA T 11 C Address:_ �3 Vi'I oon e � R� , City/state/zip: Sd 4 Yn Mir 0 M Phone A,rref you an employer?Cheek thr appropriate boxy' Type ( 1. I am a employer with :Z 4. ❑' 6:I am a general contractor and I of pincers New construction hin d): ❑ employees(fun and/or part-time).* have hired the saD-canrractois 2.❑ I am a sole proprietor or partner- listed on the attached sheet = 7. ® Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working:for main any capacity, workers'comp. insurance. 9. Q Building addition (No workers' gyp.insurance 5. ❑ We ate a corporation add its, 10.❑ Electrical repairs erns or additions regnired.I,1 officers have exercised their 3.❑ I am a homeowna.doing all work right of exerlll)uon per MGL. 11.❑Phimbing repairs or additions myself. [No worlrets'.coagr c. 152,41(4Y;and vie haves 12.❑ Roof repairs iosarance required.]t. a�vloY (No workers' 13.❑ Other comp.insurance required. •An licaot that checks box#1 nwa<also y app fill out ilx section below Showing then troFloen'oompenaetion pofiry infortmtion: t Hotneownm An sub®t U&atbdavit indleQing they ape doing all work and men hiw'6did0 COq/7BC'tCra niuet subrmt a now affidavit indicating suck :r,nuacton mat check ,boi rn ut attached an additional Am abowing the nwm ofiho sab•motieetou and rhea work='emnp:PoHCY ioformetion. I am as employer that Is providing workers'compensadon buuraniee for my e4ldyces Below is the polky and job she informatloa. Insurance Company Name: aLt+�rd Un�tr 7f,��SS �h5cnra�[e Con)0an�/ Policy#or Self-ins.Lie. #: �0 5 �A(3— a8 �0—�—Q� Expiration Date:_Jr a y—06 Job Site Address: 6Le--SL011 s� City/StatdZip: SaJ-,�/ti Ma. 0/970 Attach a copy of the workers' compensation policy declaration page(showing the polity 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 fine up to$1,500.00 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. Be advised that a copy of this statement may be forwarded to due Office of Investigations of the DIA for insurance coverage verification. I do hereby ceiX&under d m end penaltles ofpsrjuny that the Infonnadon provided above h true and correct Si tune: Dow d n #: 7�" 7yl- a295 Q/Jkid gee ody. Do not wrhe In thin area,to be completed by city orAwn offleld City or Town: Permk/License# Issuing Authority(circle one): 1.Board of Heakh 2.Building Department 3.Ckyfrow'n Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all en pk►yers.to provideworkers' compensation for their employees. pursuant to this statute, an employee is defined as"...evorYperson in the service of another under any contract of hire, 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 ibe foregoing engage in a joint enterptise'and inchrding the legalegal eo ttati m to i deceased emP>�, . receiver or trustee of an individual,Partnership,association or other legal entity,employing employees, Iiowevec the owner of a dwelling house having not more than three apartments and who roses therein,or the ocatpant 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 stasis 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 an ceptaappl[caat who has not Produced acble evidence of compliance with the hronranee coverage calm- iotffi shall Additionally,MGL chapter 152;§25C(7)states"Neither the commonwealth nor any of its POW 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-contracto(s)name(s),addresses)and phone numbers)along with tail Yes offier them the insurance. Limited Liability (LLC)or Limited Liabt'ht'y Parmerships(LLP) with no members or partners, are not regoved to carry workers'compensation insurance. If an LLC of LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Departr>ieat 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' application �e the lait or w or if you are requited to.obtain a wore is being requested,not the kers' of Industrial'Accidents, Should You have any questions companies should enter,their Please call theDepartrnent at the number listed below. Self-insured comPensationPobe7`;p self-insurance hcense munber on the to line. City or Town Officials Please be sure that the affidavit is complete and printed I ably. The Departrnent has provided a space at the bottom of the affidavit for You to fin out in the event the office of Investigations has to contact you regarding the applicant. rence inumber. in addition,an applicant Please be sure to fill in the permit/ficense number which will be used a ear,need only submit one affidavit indi g current that must submit multiple permit/license applications in any giveny policy information(if necessary)and,under"Job Site Address"the applicant should write"all kxntim 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 die applicant as proof that a valid affidavit is on file for theme permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizea is obtaining a license or permit not related.to any business or�emial venture (f.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The office 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 Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia J NOTICE N NOTICE TO a TO EMPLOYEES eW EMPLOYEES 09A, S�6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-7274900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06183 ADDRESS OF INSURANCE COMPANY (GS60UB-7728B70-7-05) 05-24-05 TO 05-24-06 POLICY NUMBER EFFECTIVE DATES EASTERN INSURANCE GROUP 233 WEST CENTRAL ST NATICK MA 01760 NAME OF INSURANCE AGENT ADDRESS PHONE# ARNO CONSTRUCTION INC 23 MOONEY RD SALEM MA 01970 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS r CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM. MASSACHUSETTS 01970 STANLEV J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. TheeI debris will be disposed of in: (Location of Facility) S d IehL Signature of Applicants Date