1 RANDALL ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Mvrcle 12C VA21M rrartfritter•SAt K 141ASALIN artx01975
'rhL-9711F74S.9593 •FAx:97t•740.9s4e
Workers' Compensation Insurance Affidavit: Sailders/Contractors/Electriefans/Plumben
An licant Information Please Print Legibly
NametBuuncwckyniratiarlmLv�tnp:
Addrcu:_
City/Statrizip:
Are you as empleyer7 Check the appropriate bus:
Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a gid contractor and I 6. ❑ New conwruetion
employees(full and/ur pan-tine). have hin.W the sub-contractors
2.❑ 1 am a sok proprietor or partner- lined on the attached sheet. t 7. ❑ Remodeling
ship and have no atnployoea Tbpo wbeoaaacmn have V. ❑Demolition
working for me in arty capacity. workers' comp. insarunee. 9• ❑ging addition
[No workers'camp. inwrarm 3. 91-We aro a corporation and its
r"laired.) officers have exercised their 10.❑Electrical repairs or addiriono
3.❑ 1 am a homeowner doing all work right of exemption per MCL 11.0 Plumbing repairs or atlJitions
myself.(no woAcrs'comp. e. 132,$1(4),and we have no 12.0 Roof repairs
insurance required.) t cmployeea. (No waken' 13.[�6t�er
comp. insurance rcquircd.)
•Aiq.ppbcanl ibol alwrko Ona al mor also nor on the cruors bu:low&%mine ubeir wwko•aunpwtrdwt puliuy iaritrentia►
' ll.mrw,wrois who tubmin Mir anldmrii iadirmi s any are duiq ttd wort ad am hire Out"rearwren HMO tubnil a ate Aldavil mtkwina ttrh.
:Caarxwes the thwit Nin bon aunt anxhd ore 2111000001 AM thowiy ON near of ar solbcontralson,Yd tbow worts'tap.paltry mlhnam oo.
/cat an amp/oyer that is providing workers'compenfadon busiurance for my rnnp/oyerr Be/ory/r rhe pu//ty and jab aiq
%rlfYfMYfj1I� � .1
Irt urance Company Name: _ / �� ., /�!> //,Wl
Policy 4 or Self-ins. Lie. 4: l[�� 3 I — ��/� Expiration Date:
l!�r
Job Sitc.Addmss: km, �� 1Ls / CityrStawZtp:_�7��fL /J9h--
Attach a copy of rho workers'compensation pulley declaration page(showing tha policy number and expiration date).
Valium w uxam coverage as required under Suction 25A of.MGL c. 152 can lead to the imposition of eriminal penalties of s
ring up to 51.5110.00 and/or one-year imprisonment,as well as civil penalties in the form ora STOP WORK ORDER and 2 rime
of up to 5230.00 a day againat the violator. Ile advised that a wpy urthis siawawnt may be lurwarded io the 011ice of
Im.,ugauuns of 1119 DIA for imurarce:ovcra.0 vcriftuUun.
!Ju hereby oenify aaJei a poiun penalNts mfperjuty that the iY/orwYNon provided ubav4 is true and correef.
Ci••n:rti,r� r�/t._o�.0 a�.u� Date•
403- 7,4'5_- -2-2
O/fkiaf mire an/p. Do not write/a tb/s arra,to As rvel p/drd by elry of Iowa OIA.Id
City or Town: Permitil.lcense 0
Issuing Authority (circle oitc): —
L Iluard of llcalth 2. Building Department J. City/foaa Clerk 4. Electrical luspccror 5. Plumbing Inspector
6. Other
C.nuaet Pcrsmt: _ ._ Phone p•
i
Information and Instructions
Massachusetts General Laws chapter l52 requires all employers ov service workers'
anti compensation
anYor their of hia.
pursuant to this Nhatute.an ess1feyee is defined as`...every pe
esPress or implies,oral or writte0.'
.An stepbJ�ts dOROed as-M indlvdteai.P��.
asaocums.corporation or other kga army,ollany two or mon
Of the Foregoing ee1W11� •Jaus ��'and
including the legal representatives of a deceased employer.or the
stooiatiou or other legal catty.employing employees' However the
receiver of teuwes o1 ere individual,P s aand who resides therein.or the oocupw of the
owner of a awaiting how dunes O"more t61n three maintapartenance.
dweiling douse of another who employs Persons to do mainteaaece.cihostructioa or repair work oo such dwelling btu."
or on the grounds or building appurtenant
thtaeto shad set because of Mich eagfloymms be deemed to be ser employer.
.%IGL chapter 152,425C(6)els°states that"s"M7 stats es ices licensing agetsey shag wlthhetd the psrlasusnee or
reaewa rats a business or a construct buildings d teas cesshnenwesMh for any.
!tor
appiicnns • haw wM W net produced ra operate
aaeeptabN svideaee of eompsues with tics lssursaes coverage regtdred."
Additioeally,MGL chapter 152.425CM states`"Neither the conutioawealth nor BAY of is Politica subs ivisioes shall
eater into say contract for that performance of public work until acceptable evidence of compliance with the insurance
ter have been presented m the contracting authority.'
rcquiromerus of this chap
Appitaes
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation an4 if
t a)oan*s),address(es)and phone number(s)along with their certiftata(s)of
necessary.supply ies L o[Limited Liability Psrtinerahips(LLP)with no emtployees other than the
insurance. Limited Liability Compare (LC) Lh
members or partners,am not required to carry workersescompensation an LLC or have
of LLP does es haave
employe .a policy is required. as advised that this affidavit may be submitted to the Department
.Accidents for conflrnnation of insurance coverage trial
Also M sure�'siwgn a is belnd e rhe uested. sot the DepartmmaMdaviL Th*affidavit should
be returned to the city or town that the application for the permit a eq
tOf
la.fuArial A"idenu. Should you have any questions regarding the law or if you are required to obtain a workers'
eompertstmon policy,please cal the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the line.
City or Tows Officials
Please be sere that the affidavit is complete and printed legibly. The Department has provided o 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
1'I�asa r which will lot used reference number. In addition,as applicant
be sure to till in the permit/license numbe
ultiple permiulicense applications m any given year,need only submit one affidavit indicating current
,hat must submit m
policy information lt necessary)and under"Job Site Address' cat
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 now affidavit must be filled cut each
yam. When a home owner or citimn is obtaining s license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves aa.)said pawn is NOT required to complete this affidavit.
I'he Otii:c of 1nvc%tiVti0ns would like to thank you in advance for your cooperation and should you have any questions,
p:cme du not hesitate to give us a call.
The Dcparment's address, telephone and fan number.
The Commonwealth of Massachtuettg
Department of Industrial Aocidents
On%*of lavesdpdow
600 Wasdinston Stfaf
Boston, MA 02111
Tel. M 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
2cviscd 5-26-05 wwwmggg.10VIdia
CITY OP SALEM
PUBLIC PROPRERTY
DEPARTNaM
��...• iu:r.lLuvtw:r•a,ls:.o
Construction Debris Disposal! Affidavit
(Mtuimd IN all demolition aid nanovatiow wort)
Ia amanh os with dw sixthedition of tht Stant Huildi"Codi,M CI►I>R sactias 111.5
Debris,and dw provisions*(MCL a 44 S 54
Staildinp Pon f _ is issred with dw condldm dw lbs debris rtsuli tQ Qom
this wart shall bs disposed o[is a properly licensed waste disposal facility as defined by MOL c
llt.! O"
The debris will be transported by:
ux -— 26
rho&--bris will be disposed of in :
z L 45 was 9L-
t,,:,,t,.�r ra.�c,til
BOARD OF BUILDING REGULATIONS r ^
PVr- License: CONSTRUCTION SUPERVISORF
Number: CS 094833
Birthdate: 06/03/1970
Expires: 06/0312009 Tr. no: 94833
Restricted: 00,
- STEVE E PARENT _
' 83 FORDWAY EXT.
DERRY, NH 03038
cox.-.....-..m.•-•-iasio,-ue---
it la' ,,�. p� _' �/ie 1°iomrmo7uiieo.CU �✓�°ac�unbl�d
Board of Building Regulations and Standards s
HOME IMPROVEMENT CONTRACTOR F
Registration: 152699 `
t ',t Expiration: 9/20/2008 '
e. x Type: Ltd Liability Corporation
T
ASAP CONSTRUCTION INC
ALAIN BELANGER''
�. .. ��...r.ei c axn=•C41ITE 415.t.as.
i
EITY-oF-8 L=,
PUBLIC PROPERTY
DEPARTMENT / /-zz p
KuaEXLsr ouscou
MAYM 130 WAMdrA ff W bhn
5'�.MASsAO/LStl15 01970
TEL 9741•745-9595•FAX:970.740.""
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: / /Z (,s 7`
�,QLie,�, al 7 0
Property is b=ated in a:Conservatlon Area YM 16✓ Histarb DWbkx YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: C L
Address: I hA.)c14 LG S 7
LZ Ael 14 .0IS '7O
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Briet Description of Proposed Work:�-,—'_�
— - Mail Permit to: 1 h'ya>�A2L 70 _
What is the current use of the Buildin97
Material of Building? if dwelling, how many units? y
will the Building Conform to -
Asbestos?
Architect's Name F ly 5./may
Address and Phone 'A
Mechanic's Name
Address and Phone
Construction Supervisors Licen * c,,i4a / 3-3 HIC Registration#
Estimated Cost of Project$ Permit Fee Caleulatbn
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields ars properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the aboveBla ed
specifications. Signed under penalty of perjury
Date
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