8 PRINCE - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY --- -
DEPARTMENT
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Workers' Companasdoe Insurance Affidavit: SedidwsiCestrwt"WElaetrtdmnsA tmbm
Antt(leant Informaden Pleam Print Latibly
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Addrenls:_ 9 ` &K 9'2 0 o 03
city/stmWZip: �"� `m ILL) ►aeonit N: Z z ,42-2/ - 71 9
Are yore a•ommpMysr7 Cheep the appropriate boat
1.0 1 am a cmployar with 1. 0 1 an a pr n=W contractor ad 1 Type dpr New conojeftstruction
(�Wrdk
(full arsllor prwjs w).• have hired dw sub-eumtsmoes s. ❑
2.W I am a sole propitiator or peruser. listed am dw attached sheet. t 7. 0 Remodeling
ship and haw no a iskommea Theme how rL 0 DamWitim
working for me in any capacity. workers•coop insurance
IN*wake.•Camp. inwrsam s. 0 we an a corporation and its ° 0 amwittg addition
nquimal offers haw exercised their 10.0 Electrical repairs or additions
3.0 1 am a hommwna doing all work right Of exemption per MGL 1 I.0 Plumbing repairs or etWidorn
myself.(No workers'camp. c. 132.j 1(4),and we have no 12.0 Ruorrepaim
insurance requi. j ► emp)Gycee Wis workers' MCI Otber
com ap. inn uscip mquird.]
A,n Vpaaaar Me ehaab eas el oar abe ae 00 as,sasua twlesr+swiq,bir taerfms' I 111kepwi"infimumAim
'tlrewbnaa who aMY dib anldrh istharb f tby ate daty d ware sse the mm anslse sasuaren atsr wore a now atndwa"Bonne"VA
{wrauara this chase too tom attar srudrd m adtt dmw Am.bwuy dw name era submits mmom sad their w AmW aieF patlry ieMaaaa
/uw uw e/wy/oyer that k povw& Vjr tvo►Aers•co myrws Aloe huwrawee jot my rtwp/oyens Bi/ow k the peBrr rrwJfol aW
Imturattrs Company Vamr. .- .. _ ,_ .-
Policy s or Salfins. Lic. M _ .. _. EApiraron Daft:
lob Site Adnss: cuy,Stawzlp.
Attach a copy of the workers,compensatfun pulley declaratlos page(showing the policy aumber and espiratlos dote)
1+ailu►e ur wcum coverage as required under Section 23A of AIGL c. 152 can lead to the imposition of criminal penalties of
fin.up in S1.5114.00 and or one-year imprisonment,as wall as civil pcnallirtt in the form of a STOP WORK ORDER and a rise
"(UP to$250.00 a Jay agaiaal trio viola(Or. Ile advirca that a copy urthis statcarimt may be I•urwarded to the Office of
1,1% auntrs ot':hc OIA °or wsurarcc covcrao vcriBcahull.
/Jo hereey rerrit jGr 'der puiws at ye Ilk s ujper/ary/Aar/Ar Lrjorwallow pvvidd Aare • /rue Ivn correct
Date• C/ 3 Z7
rht sae a: Z 7 ��l 0 0 Z 5-.5-
O/Wmf cur eIv/X AV Ivor rrr/ii AT/Air arm As be cumpk/ed by dy>or town OA-Id
City or Tows Pcrrsit/l!east a
Issuing Aulhurity (circle one): — —
I. Board of llralth 2. 9uiWing Dcpartntcot J. City/foma Clerk J. Electrical Inspector S. Plumbing Inspector
4 Other
Gmtacl Person: _ Phone p•
I
Information and Instructions
�lassachusens Gcneral Laws chapter 132 tequiees all employees to Provide+wotten' compensation for their mp eloyees•
pdRyn
is dellned as'..AvM Panne is the serrice of another under any contract of hire.
Nesttae to this%LOAe.an sg
egress or un0%A oral or wroes
astsoeiaesA eespmatios ce tiger ktpl eettity,of any two at moot
Ae t.ydgnr.is dehad a-M idd VWML rM to lid representatives of s deceased eatplo W'or the
.If the foregoing enppd to aJ�sateeprWlk aaincla i al legal deft.employing�Ployeee. However the
ooceivesr or tartest at s u►6viduaL permrabo. ts/who resides thas"er the occupant of the
owner of a dwaning bo san b@Ma@ net sates than dM sputen°r work on Vick dwelling house
to do Imaisaesaneq cus"'W"cd"or repair
dwellistg bases of ate bor'Idistg apptsaaas dmm tknll sr became of mob emplsyamw be dasaed to be tea employr.
or on the gravn�
htGL chapter I32.423C(6)also stairs dart"evairy SUN ar teed%excise&gooey stag wkbMM tM laesstaee w
Operate•badness er N cosaersee buildings Is am eesres e"Ja fir star
reeewd of 0�N evWaee at"esprases with the IssYrstae n aevarap nqu*a&.w
appoca"Additioadly MOL draper 132,i23C(7)wlss"Neidter the commes�ear am at its Political abelivvrooes shay
the performance of Public work until acceptable evidence of complittace w itb the insurance
emote law any contract tar
requiremeas of this chapor have base presented to the eormraedrtg ateioA 'oy
Appik""
Please All oust rite wetbars' aampeasmon a!'8davit completely.by checking the boxes that apply 10 Your siwauoo and,if
st�amacate(s)came(s)6 addtessles)and phooe number(s)along with dear caad1kea(e)at
neceaasy.supply C ins LC)or Limited LWNUY PwuwfsbW(LLP)with Do smplayeas other than the
meugance. Limited Liability onlpaII (L required to carry_. tasedan insurance. it w LLC or LLP doe haW
members or Putman ere aired advised 1ha<dtt s subetsitred te the Dsparemerer of Induawial
employees,a policy ra4 Also be sun to sign and date the arl7de0L The affidavit should
Accidsau for confirmation of insurance covert
ate liceasa is being regttased eat the Depareaeat of
be returned to the city or souse that the applicaioe fl r the p low ate if you are required a obtain•workare'
lndurtrial Accident p Nblall dte you vo any gltrodoat d regarding iota should enter their
conprtaiaa pokey. a eke number listed below. Self-insured aompan
self-iruuraaaa license number on the
City or Town Offklstls
_ Printed legibly' The Depsearwns has Provided n space at am bauars-
Please be stars_that the affidavit is complete and grin '
to
of the affidavit for you rill out in the evert the Office of Invastigadoru has to confect you regorging eke apPliears Please be sun to till in the purmivlicenne number which will be used as a reference number. In addition,an applies"
that must submit multiple psnmitilicense applications in any given year s�ld�wria mit a akridavic indicarins egia" __(city
policy infomntion l if necessary)and tinder"lab Site Address the applicant
towel."A ropy of the affidavit that has been offkially stamped or marked by the city or tows may be provided to the
applieant a proof that a valid affidavit is on Ale for Autrte permit or licenses. A now affidavit must be fitted out each
year. Where a have owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or pa mk to burr leaves sot.)said person it NOT required to complete this arfldsviL
fha Otiix of Inveitiptions wuuld (ate to thank you in advance for your cooperation and should you have any questions,
lisle do not hesitate to give us a call.
The Department's address, telephone and fax number
Thar Corrlmonwealth of Manachusettil
Depacoment of Iadawfal Accidents
(Mbe of IntMdSUMM
600 Washli OW So"
Boston,MA 02111
Tel. 0 617-7274900 en 406 or 1-877-MASSAFE
Fax Al 617-727-7749
2:vi>cd 5-26.05 www.mm.gov/dia
♦ � � _a; ��ie '(oomnioieweallf ✓l�LanJa�/�
BOARD OF BUILDINO REGULATIONS
License: CONSTRUCTION SUPERVISOR
`A Number: CS 029683
1
.Birthdate: 0 5/2 811 9 4 8
I
-ti Expires: 05/28/2008 Tr.no: 25835
. - Restricted: 00
WILLIAM H PRICE
PO BOX 870003 G---
MILTON, MA 02187
i;
Commissioner
II
CITY OF SALEM
- - —- PUBLIC P-ROP-RERTY--- -
DEPARrMEM
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Construcdos Debris Disposal Affidavit
(ceyuin d for an demolition and rMwvatioa work)
In uconhmc with the sixth edition of dw Stun Building Cods;7SO C*IR section t t l.S
Debris.and dw provisions of M. GL a 406!Sot
gWldfq Pon * _ is lasted with the condition that the dabris resulting <toa4
this work shall be disposed of in a properly licensed waste disposal facility as dented by WIL a
ltl.11lOA.
s will be transported by:
taame m-- r)
rho Debris will be disposed of in :
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P OF
Y PROPERTY
FDEPARMOUMMOVAICULL
TMENT
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APPLICATION FOR THE REPAIR. RENOVATION. CONEMUCTION
DEriOLPi'ION.OR CHANGE O!USE OR OCCUPANCY FOR ANY Zx>rSMG
M RUCrURIC OR BL�Irt(I
O SITE INFORMATION
L=adon Name: y
---- - Property Addreea:------ -- - - --- - -
�.
Properly is loc" N a;Caronfoll n Ana YIN HWodc DWM YIN
2
.0 OWNERSW INFORMATION
2.1 Owner of Land
Name.
Addresc
TOleph .
3ACOMPLETE THIS SECTION FOR WORK IN E7ILSM= BUILDINO8 ONLY
Addilian Existing
Renovation Number of 3toriea Renovated
Change In Use NOW
Oemolidon Fidstig
Approximate year of Area per flow (si) Renovated
construction or renovation
of existing building I I New
SOat Oesuipdon of Proposed Work:
--- -- ---Mail Permit to: - - - -
What is 00 aunW t use of the BuddhV?
Matadd d Buidkg? M&&*Wv&how man!►urmu?
we do Bwmft Conform to Law? Asbeatos9 l�
s Nana
1
Addr w aed Pew l
a -
Mschanto's Nana LtJ, "• l c
Address and Plwne "� e X 7 O O°-�
Cara ruction supMviaon tieansa S Or,? 9 to 3 HIC RegWation ft 5 9
Esftated Cad�d 0400 Pa_Fgs4w p
Permit Fee$ Eadmated Coat X$71$1000 Residen8d
EsiMstad Cost X s41/111006 Eommerd * --An Addtlonal Sd.00 In added se an
Admink&o#ve charge.
Make sun Mud ad ffelda an property and legibly wriMen to avoid dNaya in procemsk .
The undem Wwd does hereby apply fbr a SubdbV Pwn*to build tM above fated
speditsdons. sipped under penally of Wr1urY
Date �' U 7