14 PRINCE STREET PL - BUILDING INSPECTION A6r_ oil CITY OF SALEM
e PUBLIC PROPRERTY
o DEPARTMENT
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N erns 12C WAsMNGTM S Wr a SAUK M,%SAIU a 0197h
Tut_976743-9595 ♦F.ax:97F7e0.9m
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electrietansn%mbers
-%pallcant Information PrintPleage Legibly
VamC lttuvacss/orgaaintiaarinJwiJua /�'1 t
Address: -� 0- O n: �T
city/stamizip l !'hone a: `j
Are you an amploysr2 Chee appropriate be=: Eother�
project(taquired):
4&,l am a employer with 4. ❑ 1 am a gctu rai conUutor and Iewz
construction
ttnpiuycca(full and/or part-time).• have hired the sub-contractors
3.❑ I am a sole pmpricta or partner. listed on the attached shed i mg
ship and have no employees Thera subconvaowrs have em
working for me in any capacity. workers' comp, insumnee. ClBuilding additim
[No worked'comp. insurance S. ❑ We are a corporation and its iding r required.) office;have exercised theirepai s or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL umbing repairs or additions
myselL[No workers comp. c. 152,§1(4),and we have no
ofrc Pairs
insurance required.) r employees. [No workers. Pa
comp. insurance rcquimLJ her
Ain+pplicaul that checks bo rI map ako lilt uu1 the section below atowiao nApr wakes'cutupmaYiuw PC'i.y iofrrrmaeim
11•mawwrrws who submit din aAdovii wilkatbtg"i m&,h%&U wwk and tiro him"$Me eumnl,"s apes submit a pera a/Rdark indinxina rrtc►.
�C miirxvwc thm chsk this box must adaehw an addillawl alarm 4towiry dw nam0 ardhs and their watltim,carp.puiky w6rislai a
lam ton employer that 6 providing workers'compertsadon iitraranee for my employarr Below is the pplity andjob sih,
..o .....r...� IrrfarMYde/L r+.�-. / ^+.w► ar.aRum.ae.^.�' �,,�[' ,, -
Irtsurancc Company Name: �1
Policy p or Self-ins./L`ic..#,. /6)"DO 6 d,C/�(�]l�� / Eapirruon Date:: 0� 7—OF 1 /Job SiteAdlrcu:zl /Wim-C S/ ja P City/statuzip: ter?IPiyh �/V
Attach a copy of the workers'compensation policy declaratlan page(showing the policy numbar and expiratiuo date).
Failure to wcurc coverage as required under Section 25A uf.MCL e. 152 can lead to the imposition of criminal penalties of a
rink:up to S 1,500.00 antLor one-year imprisonment,as well ax civil pcnaltiut in the form of a STOP WORK ORDER and a fine
of up to SMO.00 a Jay againal the violator. Ile advised that a copy urthis slawment maybe furwarded to the Ol]icc of
I ilk,.sngmums of tha DIA for insurance enveragc verification.
I do hereby certify wader than pai :ut nu rY that the informY/loa provided ubovr i uY rrnd corrrcL
O/Jlrio/Yrt ue/y All ear write/a Air area,to br comp/eired by My or t=#-
City or 7 own:IssuingAulhurily (circle aim):t. Itoard of
11c:lith Z. Building 0cpartineut 3. Cilyffona Clerk 4. Er6. OtherPho
' • 1
Information and Instructions
tion�lass;uhusetts General Laws chapter 152 requires all employers
provide
a service f workers' tom ensiter anyoconrraettheir�of w
Pursuant to this statute.an eml/oYk is defined as"...every person
eapress or implied,Oral or wrimm-
assoeiauaat,corporation at other legal entity,or any two or tnae
An eWjdl'ar is defined as"on inditnidush.patoamship. ceased employer.or the
of the foregoing engaged in a joint enterprise.and including the legal reprssentativ s of a deY o eea However the
Other legal entity,employing e�
receiver of Umoce of at individual,Pa+inersba a association err and who fesidsc therein.or the occupant of the
owner of a dwelling house having et snare rhea three apartments andon such dwelling house
dwelling house of another who employs persons to do maintenance.cuostrtrccon or repair
or on the grounds at building appurtenant thereto shall no because of such empbymem be deemed to be an employer."
I.tGL chapter 152.¢2SC(6)also states that"every state or
renewal of a Iketase or permit local Uestsitg agttaey shag withhold the Issuance or
rate a business or to eootruet buildiep it the commoawesisis fse arty
applicant who has not prodaud acceptable whdsaee of tosoptlsaee with the insurance coverings requlred."
Additionally.MGL chapter 152.$25C(7) at'Neither the commonwealth
v many
of its
political pliaaee wi�nwrsneei
for the pert Pill work until acceptable
rcgwrementsenter into y contract of this chapter have been presented to the contracting authority."
Appliesats
Please fill out the workers'compensation affidavit completely.by checking the boxes that apply to your situation and,if
necessary.supply
sttb•e°n°u�(s)nos)•��«)�phone nwnbet(s)along with their certificates)td
Companies(LLC)u Limited Liability Partnerships(LLP)with no employee other that the
insurance. Limited Liability insurance. If an LLC or LLP does have
members or parmen,am not required to carry workers'compensation
employees.a policy is required. at advised that this affidavit may be submitted to the Department of Industrial
Accidents for comfltnhation of insurance coverage. Also M sureorolice�nsens being�he u�teQ not theme Daaps�rovmenshould
t Of d
be resumed to the city or town that the application for the permit
lee or if you are required n obtain a workers'
ladusmiat Aceideaha. Should you have any questions regarding companies should eater their
comperwtion Polity.Please Call the Deparaneat at the number listed below. Self-insured comp
,elf-insurance license number on the lam•
City or Town Ot8clsh
- ent has provided a.space at the botwm »....�«.-
please be sure that the affidavit is complete and printed legibly. a-Depai'etim
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
t'I�asm be sure to till in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/licerhae 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"ell locations in (city
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 now affidavit must be tilled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e.a dog license or permit to burn leaves etc.)said person is YOT_required to complete this affidavit.
l•hc 0171ce of Investigations would Cue to thank you in advance for your cooperation and should you have any questions,
pleuse do nut hesitate to give us a call.
The Department's address.telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OAka of Iavestlptlens
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
2cvised j-2G-US www.mm.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARr-AEm
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Tat:rQN+�h1+le �f•�t:90sa�6esN
Construction Debris Disposst Affidavit
(required rbr all datnotidan and renovatias wont)
Ia seeowlenae with the sixth ad dom o(dw State suiWing Cody,7SO Cl►1R section I l Ls
Debris,and dw provisions otMGL c 40,S 54
Suilaq pumit 0 _ _ is iswtad with the condition that the debris resulting hoes
this wort shall be disposed of in a propeeiy licensed waste dispow fbcitity as defined by MGL a
t 11.! 150A.
The debris will be transported by:
It m.or tmwtM
rho dcbds will be disposed of in
t,t.m.ter•fs.d,ry)
..t.wd..,i IV)
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4
ETPY'OF
PUBLIC PROPERTY
DEPARTMENT
n�arosrmu i#-Cc�3
APPL AnON FOR TH! RFY.�� B_KNOVATION COBS r>Qi?MOM
DEMOLIITOM OR CHANGZ Of IT3S 01t OCCIJPArtlrrv_ vn>Q ANY ZX13 rr, Q
RUC URR OR BLm n
1.0 SITE INFORMATION
Location Nernst BuYRna
4 A � 001a 0 X (,6—
A"a ly Is loosed Ina;Carwatlon Ana YIN .Ila &now DW&W YM
2.0 OWNEROW INFORMATION
JIJ Owner of Land _
L
!®a LQtic: r=y-tl-e- Y D-; - d v
LO COMPLETE THIS SECTION FOR WORK IN BUILDINGS ONLY
Addition Existing
Renovation Number of SWrka Renovated
Change In Use New.
[Approximate
molition �s*V
year of Area pe Aoor (at) Renovated
nstruction or renovation+existing building New
9dat D° 'p1! of Proposed Work:
Ids 7Can ��G k �eG� S'Gyr?.:�
✓1lG( � F s°�•� ��(n/n
Mail Permit to: d✓� 0 .r�0 st SR �-�� ice►r4• U J�''7
what is the VAm t use of u+e
Material of su�7 9 diwaNrq.Naw many unN.9 — .
vw time euMdlno cada+n Laaw/r /� — Asbestos? .�.--
AraateWs Name
Addna and PAaia I 1
M.d+.Na's Name xAddress Wd phone
.=wwue*m Liar !�Co�f_ 7�16 HIC Rd t e/ 7
EstlrnaMd Cost of Project i�1 Pennllt Fee Ca1d+IMlon
~M Foe i 112 Eadmetad Cat X i71$1000 Residential
Esfrnaad Cat X i411i1000 C mnwcid — --An AddMional SLOO is added as an
Make sun that aM fields are Properly and WW*wtftn to avoid delays in proeesdnS
The W4we sed do"Eby apply for a Ouudkq Perm*a b M above stead
sp@yWoma• Signed under per+a*Y of PwtmY
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