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12 PRESCOTT ST - BUILDING INSPECTION Y PmWI l La@Wd In Yam_ ✓ aad "Ns �--- mwwaft ma I- , " b plop ow Low"In r/ Omura PEIMMT ,ICATiON POQs Pool. (CYsb wN0lNwar as*) �� Do*- �� PLaBM ML OWT LAMLV a C011Pw&f TO AVOW OL AVO W Mom TO THE INSPECTOR OF MOM to bxlYd a000ldYp me a sWad her* ai>P�a for a PM* lda l01tla bYowiiq SIMMONNOW Omlar$Nama / '/G� � �I Sfi G�fr + Afteaa a Ph.. �� Ch��.T fT AlaNrao<,a Naala /U/A AdrMwa a Phone . Maohmics Name /lF-/ 162A VAIM it ar P PM d wlaW l WANa arlenat w rra� a a dwaalE,lor Iwn Noy MlaaasZ o`—r—.--- wrwrl�rw�alawv lama d GO 40, ' W LloMin• N 0► a aaa d 0 APOWW P Tr aor�uNDaTNE oucwvnoN OP WCW TO U DONE MAIL POW 7 0 C�1J J ST -f� 0/ 9 7 0 i" No.2z PWMI To pL- Z 24A S LOCATION le e,�wI44- PQ�AIT ORANrED � " �A z3 te�� OF The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Lettibly Name Mumnessopnizatio»/l dividt>w '(I CCU Address: 5 7 &LL6 re 0/- City/state/Zip:��¢rpn� 71/l '( 17 S Phan# Are you an employer?Cli ,the-tpproprlate box- Type of project(required): 1.Q I am a employer with 4. Q'I am a general contractor and 1 6. ❑New construction employees(fan and/or part-time).* have hired the sub contractors 2.Q I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working,for me in any capacity., workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ we arc a corpgratiom`add its, regnired.l:, officers have eze crsed thitir 10.❑ Electrical repairs or additions 3.Q I am a homeownerdoing all work right of exeaglticjn per MGL' 11.Q Plumbing repairs or additions myself [No wmkcW,comp: c. 152,§I(4�;andwehaveno , 12.❑Roof repaus insurance required;)t, empkryeea [IQo arorkeis' ; comp.iaauanc'regnrred j 13.[- Other 'Any applicant that oheeb box,#1 mM also fill out the ee an below showing ffiek.,workom'coriq�gtee0ion p7heyinfomrtion: t Homeowners who mbno On affidavit mdwatmig ibex are doing all wodt and then We'outmde wvmwtm impel submit a new affidavit mfta ins such :ContracEon that cheek this bbi mw atmched as addiliond silent abowiug the num little m ooatreclon a d ffiea workers'comp,polity ivforrrtation• lam ens er that is rovidin workers'eo f my enfptoy Ploy p d mpensatlon buurarrre or ett Below is thepoliry and Job site information I / Insurance Company Name: f�X�� b'or Fc. /V L 4 Policy#or Self-ins.Lia #: i� 36 3J G 6 Expiration Date: 71 Z�,/ Job Site Address: 1 Z P 1� ��— City/State2ip: , /¢�pM jA 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 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 Investigations of the D insurance coverage verification. �Y be forwarded to the Office of I do hereby cerdfy rthe pains and penalties ofpaJary that the information provided above is true and correct S. -- D Z •Z 6- Phone#: Q(jicld use only. Do not write br this area,to be completed by city or town offlciaL City or Town: Permit/Llcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone# Information and Instructions workers' compensation for their employees Massachusetts General Laws chapter 152 requires an employers.to prov* Pursuant to this statute, as employ"is defined as"...every Person in the service of another under any contract of hire, express or implied,oral or written" P�Ya defined "�individual,partnership,association,corporation or other legal entity,or any two or time An and'including the legal represeaWjvcs'of a deceased employer,or the of the foregoing engage m a Joint enterprise, to ees. However the receiver or trustee of an individual,partnership,association or other legal entity,emp Ym8�P Y ant of that house having not more than three apartments and who resides therein,or the occupant owner of a dwelling lo m to do maintenance,construction or repair work on sucb dwelling house dwelling house of another who employs persons or on the grounds or building aPPw=mt thereto shall not because of such employment be deemed to be an employs." MGL chapter 15Z§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(i)states"Neither the commonwealth nor any of its political subdivisions shah of public work until acceptable evidence of compliance with the insurance enter into any contract f or the perform�rx ter have been presented to the contracting authority.- Applicants of this chap Applicants please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supplY sub-contractors)name(sl address(es)and phone numbers)along with their certifi*s other than the iusnranee. Limited Liability Compa nies(LLC)or Limited Liability.Partaershipa(LLP)with no employ members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have uired. Beemployees,a policy is req advised that this affidavit may be submitted to the Department of Industrial ould Accidents for confrmation of insurance for eth permit overage. Also besure f liccnssip eDis being requested,not the Deparerted date the aflIdAVIL The affidavit nthof lndustrbe returned c the city h town that the application nquestions regarding the law or if you are required to obtain a workers' couipe iaation Policyutg,; Should You have a� compensation policy:Please:can thtDePartment at the number#fisted below. Self-insured companies should enter their self-insurance license nu m er 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 atthe both of the affidavit for you to fill out in the event the Office of Investigations has to contact You regarding aPP applicant addition,an Please be sure in fin in the permit/license number cos in will been yea a�o submit� r.n affidavit indicating went that must submit multiple pemrit/license applications in any given Y policy information(if necessary).andunder"Job Site Address"the applicant should write"all locations in (city or of the affidavit that bus been officially stamped or marked by the city or flown may be provided to the town)." A copy f that a valid affidavit is on file for future permits or licenses. A new affidavit most be fined out each applicant as prop permit or not reb►ted;to any business or commercial venture . obtaining a license owner or atizen is twining year.Where a home own (i.a a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would I&e to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a can. The Department's address,telephone and fax numbs: The Commonwealth of Massachusetts Department of Industrial.Accidents 0Mce of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwwims.gov/dia CITY OF SALEMO MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEV J. UEOyICZ, JR. TELEPHONE: 978.745-9595 EXT. 380 MAYOR FAX: 978-740-9a48 Salem B ' D IWdin De artmen t 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. The debris will be disposed of in: 3<r (Location of F 030)� Sigtfature of Applicant Date