26 SOUTHWICK - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY _
DEPARTMENT
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TALL 976-743.9595 a FAX:9M740•9e46
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electridans/Plumbers
ApPileant Information Printease Legibly
_ Name t—
- -- - - - •_ •• -
Address: /
City/Starcizip: Phone N:
Are you an employer?Cheek the approp►ht e�bt
�1 Type of p►aJau(required):
1.❑ 1 am a employer with 4. am a general coutr=w and 1 6. ❑New construction
employes(full sn fur par 4me).e have hired the sub-comnctora
2.❑ I am a sole proprietor or partner- listed on the attached shod. t 7. ❑Remodeling
ship and have no employees Theca cob eantnetara have V. ❑Demolition
working for me in any capacity. workers'comp, insurance. 9, ❑ Building addition
(no wmkem'comp, insurance 5. ❑ We are a corporation and its
required) otTtcers have exercised their Ill.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additions
myself. (No workers comp. c. 152.41(4),and we have no 12.E]Roof repairs
insurance required.] t employees.(A'o workers' 13.Q Other
comp. insurance required]
Any applicml the chocks ban 01 moY able fdl"the scorn Lwow showing their wakar'o"Pabod"Pu1iry io6xmWioa
I1w wnan who wbapl rho aflldsr&indicating they an de og as want and?lira hoe atatids eaarraean mWl.uhnnk a row aaldavb indioaing such.
{umratwes Ilia chatk des bOn nest aeaeltwd un addiUpW duet drawing the name tithe wb4amxoas and rhea warkwo,cwp.policy informants.
/um an employer that Is providing workers'compeataden hosurance for ray employed? solON/a the pat/lc apd ob sit;
..,.y�..,. y„i(�jwmufiaA.�r'�/'wl+ws .row;— � ••.+ —•.
Insurance Company Name:
K)licy 4 or Self--ins. Lic.M: EApiration Date:
edJ,)b Site .Address:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure tv secure coverage as required under Soction 25A of.*vIGL c. 152 can lead to the imposition of criminal penalties of a
fine up In S1.500.00 and/or one-yea imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
sf up to S250.00 a day against the violator. Ile advisad that a copy of this statement rwy be forwarded to the Office of
Ile\'C�Ihall Otte of the DIA for miuranee CtlYera St' v"iflcation.
/do hereby terrify under the paias and penalties afperjury that the in/ormadon provided above Js true and correct
- Dare
Plvn:c a:
0fl ia(use orr#t Do cat wr/te/a this area,to ile comp/ded by a/ty or rows o/jli laL
City or Town: Permit/IJcease Y
Issuing Aulburily(circle one): --
1. Board of lleahh 2. fiuildinU Department 3. CityffoNa Clerk a. Electrical Inspector 5. Plumbing laspector
6. Other
Ci;ntact Person: _ Phone p:
Information and Instructions •. .r E:
♦lassachusetts General Laws chapter 132 requires all employ cMtov s�erviee atOtkgW compeusaation any ontrad of hire
for their cmP1OYCeL
Pursuant to this statute,an rarpfoyre is defined as"...even'person
eapcess or implied,oral or written."
An e+ der ew is defined•"m individual.pattRWWWP.awmsaoa.corporsuna or other legal entity.or naY two a more
of the foregoing engaged in a joint enterprise.and including the legal rcPcc tadves of a deceased employer,or the
�sweian"or other legal entity.employing employees. However the
receiver err«ustee of as individual,Parmers�P. and who resides eherein.err rho occupant of the
owner of a dwelling bows having not more them three aparen ceft
employs Persons to do maintenance.cooatruction or repair work on such dwelling house
dwelling house of soother who
or on the grounds a building appurtenant thereto shall not because of su cb employmwt be deemed to be an employer."
;.tGL chapter'132.42SC(6)also states that"svwy state or Meal Iketsshg agea ty"Lail withhold the Issttttsp or
raft a basis*"or to"imushvet buildings Is the cemsnoawes"far say
renewal of a lleesw or permit too t>e
appncaa wbo ban act prod -eeteptabht evidaw o[tooplhtaes with the iastiratt es coverage required"
AW
Additionally.MGL chapter 133,§23CM states"Neither the commonwealth owacy of itsOf Political ance wi subdivisimia nsuanee
enter into any contract far the Performance of public work until acceptable
have hem presented to the contracting atidlaity"
requirements of this cboptar
Applicants
Please fill out the workers' compensation attldavit completely.by checking the boxes that apply to your situation sad if
neeessmy.supply subcontracro4s)risings),address(*)and phone Outttber(s)along with their certificate(s)of
necesotiee. Limited Liability Companies(LLC)tr Limited Liability Partnerships(LLP)with no employees other than the
members Of P errs oa r��to carry workers•compensation insurance. if an LLC or LLP does have
employees.a policy is required Be advised that this afrut vit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverall 0. Also bit 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 Accident. Should you have any questions regarding the law or if you are required to obtain u workers'
compensation policy.please call the Department at the number listed below. Self-insured companies should enter their
,elf-insurance license number on the ap1 •
City or Town Off cisb
Please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom,
of the affidavit for you to fill out in the event the•OtFice of Investigations has to contact you regarding the applicant.
till in the perm
Please be sure to it/license number which will be used as a reference number. In addition,an applicant
multiple permitilicense applications in any given year,need only submit one affidavit indicating current
that must submit m
policy information ult necessary)and under"Job Site Address"the applicant should_write"ail locations in_(city or
(iftown)."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
yam. where a home ownec or citizen is obtaining a license or permit not related to any business"commercial venture
I i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
IN; Ot fix of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us u call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
pIIta of Inveadpiden
600 Washingttn Street
gOUM MA 02111
Tel. #617-72749M ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
2cvibcd 3-26-U3 www.mass.gov/dia
- ..„.,�- -«.. ....- ..ere �. ._ � t . ... ...... . .... . _ .. _. ..
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 117846
Type: DBA
Expiration: 12/4/2008 Tr# 125429
CASTLE CONSTRUCTION
BRIAN LEBLANC
9 TIBBETTS AVE
DANVERS, MA 01923
Update Address and return card.Mark reason for change.
;-cAl v 50M-WM-PC8698 Address ❑ Renewal 0 Employment Lost Card
-Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 117846 Board of Building Regulations and Standards
O)f
Expiration: 12/4/2008 Trig 125429 One Ashburton Place Rm 1301
Boston,Ma.02108
Type: DBA
CASTLE CONSTRUCTION
BRIAN LEBLANC
9TIBBETTS AVE
DANVERS,MA 01923 Administrator Not valid without signature
Aofim ildingwcgulut, /�O°°ac/u�eek2
Board of Building Regulan ns snd Standards
Construction Supervisor License
License: CS 54882
Blrthdate: 9/17/1962
Eko!i" 9/17/2009 Trill 5787
Restriction: 00
BRIAN A LEBLANC
9 TIBBETTS AVE
DANVERS,MA 01923 Commissioner
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CITY OP SA I"
- PUBLIC PROPRERTY -- -
DEPARTNEM
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Construedon Debris Disposal affidavit
(required rw an danelidom and renovation work)
In axordenee with the sixth edition o(da State Building Cods.730 C161K soation 111.s
Debt*and the provisions o(MGL a 40.S Sk
9%mm Pon &p _ is issued with the condition dust the debris resulting Sofas
this week shall be disposed of in a properly licensed waste disposal &dUty as defined by WIL a
111.S 15OA. J
The debris will be transported by: / j n
rho d`-bris will be disposed of in
- M+ntr�f facdny)
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4
EI'IY OF
Al PUBLIC PROPERTY
DEPARTu&N T
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AlpL�A_TION FOR RZ ?OVA37ON. CONEMLrC a"
DE.r[OLEEM OR CHANGZ OF USZ OR OCCUlMM FAR ANV >ijcrsMG
1.e BITE INFORMATION i
LocM*M Nam Q G
--- r,
Property k located In s;Corauvadon Mae YM Hldodo t7lsM YM
2.0 OWNERSIM INFORMATION
11 Owner of Land
Name:
Address:
Telophow
"COMPLTt E T1fIS SECTION FOR WORK IN E>I!S?!NQ BUILDINGS ONLY
Addition ExION
Rerwvation Number of 3todaa Renovated
Change in Use Now
Demolition Existing
Approximate yew of Area per floor(sf) Rarmated
construction or renovation
of existing building New
adaf Description of Proposed Work:
0
--- -- ---Mail Permit ta:
tNhat is Via awrwd use at the 8uddkV? '.: . • _.
MlabrW at Bu�dIn01' Itdweirq,how^�uNb9
we*0 euildtn0 Cadbrnt 0 tow? Aabestos4
A,ddrw and Pharr
Uaolwdit Naew
Addram and Phare rL HfC i
ConWudlon��u,w"i
EaWnaled Cost d Pow4 FN Cal m"s
P®rrnit Fee
Estlmsead Cost X$7/i1040 Reeldae dd
Eswr and Coat X=41/i1000 ConwnaretaL--An Addlitonal i6A0 is added as an
AdwAilsts"dwpa•
MlaM mm that an flelde are property and ► gp*written to avoid delays In proeeeaing.
The w"sipned does hereby apply for a OuUduq Pwn*to build to the above elated
apadpkoone• SWAB under?mft of pwNw
Date %l
I
ry a
�ts a
a 5ge