27 SCHOOL ST - BUILDING INSPECTION CITY OF SALEM
t PUBLIC PROPRERTY-
`o`� DEPARTMENT
:.,vttoai>:r oatst:ttu
Msvcta 12t:tsxsw.w-ralaS'ntear•S.t
t ru.IdASKAC7 n'.tlTtti 01970
978.745.9595 is F.vx:9M740.9a46
Workers' Compensation Insurance Affidavit: Sailders/Contractors/Eleetriclaus/PMmbers
Applleant Information Please Print Legibly
NaMC laucincsa/(kYaniratiotvltnitvtdtnq: U 7 Pr"c'� �®
Addreas: �/ �(/��ti� /�✓t�
City/Stam/Zip:_ 4;�—O 5r- tf�
Are you as employer?Cheek the appropriate best
T
ypet(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and tNewconstruction
2.�empluycca(full andtur part-time).• have hired the sub-contractors
am a sole proprictor or partner. listed on the attached sheet, t eling
sh and have no employes Then wacontraetors haw tionworking for me in any capacity. workers'comp.insutance. g addition
f No workers•comp. instrrance 5. ❑ We are a corporation and its cal ruquimd.) oRRcers have cxcrcised their ❑ repairs or additions
3.❑ 1 am a hortmowner doing all work right orexemption per MGL 11.Q Plumbing repairs or additions
inyselL(No worker??'comp. C. 152,¢1(4),and we have no 12.Q Roof repairs
insurance required.) t employees.[No workers'
comp. inwrance required.) 13.0 Other.
•Apq apithcam the edxYs Ile NI mine also Rll w at,Well"Ixbw Yawing ibL*Work ass,eumpreryiun puliry iofiwmwiwt.
, it,w wntn who Submit this tdtldpu indicating stay ass doing Yt work and than hire outswo enmaxnws pus"Submit a now affl avd indicating Such.
{'aurxwn that ckvk dtp ban stet aYaehad an addiduoul Shan.bowing the now orate and thew wu,kaa'Owes.pulicy infbrnutleta
MISS I
/Site an a nptoyer that Is providing workers'cotnpenradoa lruaranee jot.my employees Below is the pis/lay and job aid
injNrwatian.
Insurance Company Vame:
Policy Y or Sclf--ins. Lic. tY: Expiration Date:
Job Sim .address: _22 SC N c a/S 7'—' Selz;-r City,Jlawizip: 11k!%=
A«ach a copy of the workers'compensation policy declaratiots page(showing the policy number and expiration date).
Failure w secure coverage as required under Station 25A of.IGL c. 152 can lead to the imposition oreriminal penalties of a
fins up as 51.500.00 and/or one-year imprisomncnt,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. lie advised that a copy urthis statumum maybe forwarded to the OlJice of
Iu�csngauotu ul'du DIA for insurance covcra4u vcriticinan.
/Ja hereby certify NN`Jet. 7
Mo "
d penis/tier ajper/Nry that the in/ermaden provided above it true andcorrrcL
Ci• ,atura / Date l/ �/� /
O f&/rd Nse aN/y. DO,tot Wile/n this area,to At raMp/Nedby City or fawn ofa-Ad
City or Town: Pcrmitll lcettse N
Issuing Authurily (circle arc):I. Duard of Ilealth 2. Building Oeparttncot J.City/form Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C otact Pcrsonc - s Phone p:
Information and Instructions
Massachusetts General Laws chapter 132 requires•all employ�toprovide
ovi edie erworvicc a compensationer �nny tbe'r ere of hire.
Pursuant to this statute,an rtw/foyes is defined as`...every person
eapress or implied,oral or written"
Of e«�Ya►is engage as"as int ra ual.is Partnership.inch aweisdau.corporation or other legit entity.or any two a in"
Of the foregoing engaged in a joint entetpriae,and including the legal representatives of a deceased employer,er the
uwciation or other legal entity,employing employees. However the
receiver at
artier of o individual,parmershnP. and who resides therei4 air the occupant of de
owner of a dwelling notes having not Wrote dun thttes apgrahhanb
dwelling douse of another who employs persons to do maintenance,convection or repair work on such dwelling house
"on the grounds or building appurtenant i ereto shall not because of MICA employment be di:emcd w be an employer."
MGL chapter 132.425C(d)alto stave titer"every stars or(Deal Hei asiag agency shall withbold the lusts ses or
In the coeamoawealsb far any
renewal of a Ileeass or permit to.opsraM a basMe or to a splisaide withtsO���coverage required."
applicant wbe beg act produced acceptable evideaeg o[eomptlaace o[its IhnesJ anbdivisiong shall
Adaidualty.MGL chapter 152.423C(7)states"Neidwr the commonwealth nor any Po
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of ibis chapter have been presented to the contracting
authority." llw�
Applicants
Please fill out the workers'compensation affidavit completely.by checking the boxes that apply to your situation sad if
ntb.eontsecve(s)ems).addrers(es)and phone number(s)along with their certificates)of
insurance. Limit ieg L or Limited Liability partnerships(LLP)with no employees odor than the
insurance Limited Liability Companies carry C1 n insurance. if an LLC or LLP does have
members or partners,am not required to carry workers' davit ratio
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverages 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 a license is being requested, not the Department
industrial Aceidcats. 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 hated below. Self-insured companies should enter their
self-insurance license number on the appralrow line.
City or Town Officials
,Y y' Partm p P
Please be sure that the affidavit is coinplefe and prmte3 I nbl". Tlie°De ehthas rovided n space de botwta.. .
of the affidavit for you to fill out in the event the office of Investigations has to contact you regarding the applicant
t'leasc be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must sublait multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Addreu' the applicant should write"all locations in_(city or
town)."A copy of the affidavit that bas 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 Of citizen is obtaining a license or Permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves ere.)said person is NOT required to complete this affidavit
I'hc Otiicc of 1%vestigatons would live to thank you in advance fur your cooperation and should you have any questions
plcaae des nut hesitate to give us•a call.
The Department's address,telephone and fax number:
The Commonwealth of Masaachtlsetts
Depathaent of Indlisttial Accidents
Oflkt of Invadpideas
600 Washington Sftd
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASWE
Fax 0 617-727-7749
zevised 5-26-05 www.man.gov/dia
CITY OF SALEM
R
- - - PUBLIC PROPRERTY -
DEPARTMENT
]LIB.+ 111''1.�Rw—:Jasi 7tLT•'j�tFlt.ltA�Ylt2a.t11a::9
Ttl:'n4w7aY�9s1�L<.�4AJ�6NM
—F
Construcdos Debris Disposal Affidavit
(raluired for all danolition and tenovadaa wont)
In mwdsnee with the sized ed doe of dts Stttte Building Code,7So CMR soetias 111.5
pcbrij6 and due provisions otMtGL c 40.S A.
gWldird Famb A _ _ is issued with cite eondldon that the debris meth tS loom
,his wont shall be disposed otin a property licensed waste disposal facility as defined by.UGL a
t11.S15"
The debris will be transported by:
_. lname of tlwt.r)
rho&-bris will be disposed of in :
!N1AO
(fit 63 e f-o eOnl
i
� 1o �
• .w
q . _
�BORD'QF B�U1Lfll G REGULATiON3: ,
Lice nx;: CONSTRUCTION.SUPERVISOR.
Numper. CS. .
`.: .s. �^F�epires 05I25/2008 Tr.Oct 2.6865.: . .
Rp5tP6f{d•r Oft t , -. - y
ROBERT F DOLAFF -
IPSWICH MA 0193$.t,-�'4,- Commisaione� -
4"
r
CI x V OF
PUBLIC PROPERTY
DEPARTMENT
�tnras 130 V�aw�nr ssmr•s�a1AfApRf�ry'p Ot.»
t1a:m�asfsa).t�s s�a7�►tNs
AlPLICATION FORTH! REIlAI11. RZMW k UON, CONRUCTIOM
DEMOLITION.OR CHANGE OF USZ OR OCCUPANCY_ FOR ANY >P MI NG
CIMBROBAULDING
. LO SITt INFORMATION .
Locadon Nemu
Proarly Is kxwbd In s;C n@wvsdon Ana YM Hkftft ONMIot YM
2.0 OWNERSHIP INFORMATION
2.1 Owns►of LmW
Name:
Addrm c �;L 7
Tslsphons: . $' 4/ ' e)5 O
ff
IS SECTION FOR WORK IN EKIiIIIMp BULDINGS ONLY
Existlnp Number of Siod" Ranovated
Chants in Use Nsw
Osmoudon s g
� �
copns�cdm yew
r renovation ass per Aoor s Renovated
of existing building New
adat Description of Proposed Work: J
!1/S7 .'g'r/ G✓�'l AIS Cv^Q'7�PY�% �" �2 t v✓l ��'/O/C
--- —- ---Mail Pemlit to:
What is gw urgent use of the SLAOw?
N dwetin¢NOw many���, Y
matww at su~ a Asbesbs?
Wig Itra� �m COI b la"'?_ —
Ardilad's Name
Addrasa and Phan l ) -
Medwm*Nana
cc suparviaors txaw r % HIC gepiss&Wn s i 53 3 2 7
Es*rdsd coat d Pnnjed s /, r n Pr"i Fee
Permit Fee S Q- Eadmaad cod X$7I: 0010 Residential
- - --_ _ _ - Edlndad Coo X$11161000 Caenraeia4----An Addillond=6.00 Is added r an
Adnirdstra" n
Make sun Ihd an nalde we property and isw*writlan to avoid deleve in ProeessinW
The undera wd do"Eby apply far a BuUdinp Permit to buld to the above stated
6W:
SIE;ad urww Parody of Psr)+rY
I�
0 s S
0
`d