3 ROSEDALE AVE - BUILDING INSPECTION (2) fL"1"mfm&#A a APPROVED 8Y UK
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CITY OF_SALEM
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BWLDW MRWT APPLICATION FOR:
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KEAZE FILL OUT LEGIYLY&COMPLETELY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF BULDINOS:
The undsraWmod hereby appYas for a parmif to build according 10 the 10W"
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sialrED UNDER THE PENALTY
Of PENURY
DESCRIPTION OF WORK TO BE DONE n
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
RI�WERIP.7•DRISCOU
MAYOR 12C WASWNG'ION S'1'Rr r♦SALEM,MASSAC USE 1]'%*0197e
Tra.:978-745.9595 0 PAX:978-740--9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 4 Please Print Le ibl
Name (Business/Organization/Individuul): /l N4
Address: C 0IF / Q/
City/State/Zip: L_-e i o Phone #: �7tf— 72 fP73�I
Are you an employer'.'Check t c appropriate box: 'Type of project(required):
1.❑ l am a cm Io 4. ❑ I am a general contractor and I 6 New construction
employce� Il Zrd/o part-time).*
have hired the sub-contractors ❑
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7.4 Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work fight of exemption per MGL 1 I.❑Plumbing repairs or additions
myself. [No)vorkcrs' comp. e. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box GI must also till out the section bit ow showing their workers'compensation policy information.
t Ilumeuwnera who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new of idavit indicating such.
�Correcwrs thal check this box must anachaxl an additional sheet showing the name of the sub-commciors and their workers'comp-policy information.
l tun am enrplayer that is providing workers'compensation insuranee for toy eniplayees. Below is the policy and job site
information.
Insurance Company Name: ► r^p"� ��....9 ��:_St�f✓c�t/12�C1F �I�1�/llioll�
Policy#or Self-ins. Lic.f#: p06 JA AlYtI7 7341 Expiration Date:
Job Site Address: City/State/Zip:
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 S1,500.00 and/or one-year imprisonment,us well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/rho hereby ccrti y ruder t pains nn pXeo perjury that the information provided above is true and correct.
Sienalure: �f Date: o`G 6
go
Phonc#- / If- 771 6 73X—
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#-- ---_-_-___--
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: _, Phonc#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person 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 the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant 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 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 lit, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
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-contractor(s)nane(s),address(es)and phone nuntber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have "
employees,a policy is required. Be advised that this affidavit may be submitted to the Department 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 the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number 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 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license 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"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 new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of hmvesrigetions 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 021 t 1
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax#617-727-7749
www.mass.gov/dia
SUN 26,2006 05:23P 19783526619 page 1
.34 (Policy Pf0visi0ns: WC 00 00 00 A)
67
NY INFORMATION PAGE
,wac WORKERS COMPENSATION AND EMPLOYERS LIABILITY
POLICY
INSURER: TWIN CITY FIRE INSURANCE COMPANY
HMTFORD PLAZA, HAJRTFORD, CONNECTICUT 06115
NCCI Company Number: 14974 JARTFORD
HE !X
Company Code: 7
o suffix
LARS RENEWAL
�
� POLICY NUMBER: 08 WEC NX6734 0p
Previous Policy Number- NEW
HOUSSNG CODE: SB
m I. Named Insured and Mailing Address: KEITR MACDONALD
N (No., Street, Town, State,Zip Code)
0
0
FEIN Number: 043522249 253 CENTRAL STREET
GEORGETOWN, NA 01833
i� State Identification Number(s):
i�
The Named Insured is: INDIVIDUAL
Business of Named Insured: CARPENTRY - FINISH & TRIM ONLY
Other workplaces not shown above: 253 CENTRAL STREET
GEORGETOWN MA 01833
2. Policy Period: From 06/10/06 To 06/10/07
12:01 a.m., Standard time at the insured's mailing address.
29M Producer's Name: TARPEY INSURANCE GROUP, INC
r� PO BOX 567
WAKEFIELD, MA 01880
�m Producer's Code: 083924
MW Issuing off-ice: THE HARTFORD
4401 MIDDLE SETTLEMENT RD.
I800tj 962ARTFO6RD
70 NY 13413
Totai Estimated Annual Premium: S3,595
290 Deposit Premium:
— Policy Minimum Premium: $500 MA
Audit Period: ANNUAL
Installment Term:
The 13014Cy is not binding unless countersigned by our authorized representative.
Countersigned by jl �, ��,. 44 G ,
numvnze0 presentative �
Date
Form INC 00 00 01 A (1) Printed in U.S.A.
Process Date: 05/03/0 6 Paget (Continued on next page)
ORIGINAL Policy Expiration Date: 06/10/07
CITY OF SALEM
3y kaki PUBLIC PROPRERTY
r _
? �a t DEPARTMENT
e4gy
KIMPEKI.F.Y DKISCOIr.
MAYOR 120 WASHING I.ON STREET 1 SALEM,MASSAC.HDSh:1IS 01970
TEt:978-745-9595 4 FAX:978-74&9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# -_- — is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
MAC l od
(name of hauler)
The debris will be disposed of in
(name of facility)
/t¢ /33 Gromdnr_�-
(address of facility)
signature of permit applicant
�A'64
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