11 SUMNER RD - BUILDING INSPECTION (2) CITY OF SALEM
T/ PUBLIC PROPRERTY
- •� � o c� ��- �� - DEPARTMENT
w{\IaratEY nafra:Ul,1
)vL\Yaa 12C l A*&%X-•r W SnV r a SA tsar,lf.\suc.-1 a.wrrs 619n
'reL 9711-745.95% •FAX:9M740.9a46
Workers' Compensation Insurance Affidavit: Builders/Contracton/Ekctriclans(PMmbers
applicant Information / Plesse Print Legibly
Name-
tauvnculOrgaeiratforvlrutivtdlwq:_. 1 )-; !' oiy S
Addrem: 3 3 s M-+, ST.
City/statc/zip:_ 36 -l5,PA I'hotte 0.- �J� s3� -,'i8 8
e u an employer?Cheek the appropriate bon 'type of project(required):
1 am a employer with 4. ❑ 1 am a general contractor and 1 6
employees full and/ur have hired the sub-contractors ❑New construction
( pert-tine).
2.❑ 1 am a sole proprietor or partner- lined on the attached sheft t 7.XRemodoiiag
ship and have no employees Them strbcontraetora have V. Demolition
working for me in any capacity. workers'comp. insurance. 9. BwWf❑ rag rdditiaa
(I�o workers'carp. insurance 5. ❑ We am a corporation and its 10. Electrical
required.) officers have exercised their ❑ repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.§1(4).and we have no 12.❑ Rswrrepaim
insurance required.] t employees.LNO workers'
comp, insurance required.] 13.❑Other
Atq Viihoad the chucks boa of mast also lilt Our am ugiao tstaw dmwiag{aeit wwtsW cumpm m km pdicy imbm{t{Wipy
I l.mwwrmn who submit dmi Nis a must
as iamil a,a li am Ju. an wart cad Nse him oatilds cwanamn mau aWnk a nut.atndavid indicaing sarh.
f..t{nwrs Ow chtxt ate ism mart aeachad an additional Jwn Jawing Nd mmo atram mdome aria,and Ikeir work=,cm*.Porky iafni a ko.
/oar sin earployrr that Is providing workers'compenraton hataramce for ary employers Below is the //c d sll�
- informattiaa a......._ / q - ..,,..... ,— -- ,-- - .«�-.�,.., ?.W y._an1ob
__. .._ .«.»� .,.- �.-•.
Insurance Company Name: f �'/\-APV/T Of- S'TIyQ-,f 1L
Policy g or Salt-ins. Lie.0: �C 1l DA(.o O o ^ Expiration Date: '6,09
Job Site Actckcss:// ,2& A� &t� �/)... City/sIatuzip: e546e,*f // W '
Attach a copy of the workers'compensation policy deciaratloa pass(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.MGL c. 152 Can lead to the imposition of criminal penalties of a
tine up at S1.500.00 and/or one-year imprisonment. is wall as civil penalties in the form of STOP WORK ORDER and a fine
of up to$250.00 a Jay.igumst the violator. lle advice that a copy or this statement may be forwarded io the Office of
III\'��Il�al{Ulla JI Lhc DIA for iniiwancc eoverayc vuril cation.
/Ja hereby certi an ! pm' /t' r r/u y that rho iafarmaf On provided above is Irmo mild correct
[1217flkcimf size ON& /b Nor write/a this area,m lot caaaplated by e/Iy of/otvw o/�a laLty or 'town: PermitlLleenstuing Aulhurity (circle oitc);1"i'd ofIlealth 2. Building Department 3.C(tylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
Gnttact Pcrsou: _ Phone q:
G
Information and Instructions
Massachusetts General Laws chapter 132 requires all employe�roviservice a anothercompensation any contras of hire. '
pursuant to[his statute,an empfeyee is defined as'_.every Pe
enptess or implied,oral or written
1u esa layer is defined i s-so individual.Pnemaeshtp aaoetalDiM corporation at miter legal Canty-or any two or toad
of the foregoing engaged in a joint emetprim.and including the legal representatives of a deceased employee. v the
"location or other legal entity.employing entployeea However the
roceiver er trustee of m rudividng pardarnhnP. and who raids therein.at the Occupant of the
owner of a dwclliag betas having not more theses clado mainteapafonance.
dwelling house of another who employs Perm"to do maintenance, f such nspi or repair work oa such dwelling house
or on the grounds a bui(elitte appurtenant thereto shalt not because:
o[each employment be deemed to be sa empty«.
sty shag withhold issuance or
MGL chapter 152.423C(6)also states that"every state of'Ord lkensing age ea
renewal of a license or permit to operate a btutsua or to astr aad buildfnp 1a the comssoawallk for say
app'teastt who has net produced evidence of compose"Wilk the insurance coverage required."
Additionally.MGL chapter 152.423C(7)state Neither the commonwealth nor bray.of is political with vision rand
for the performance of public work until acceptable evidence of compliance with the insurance
recur rats ntsany f this c authority."
requirements of this chapter have bra presented to the contracting
App'trants
Please fill out the worker'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary•supply y�.eontracror(s)name(s),addreas(es)and pbom ntunber(s)along with their certificatc(s)Of Than the
insurance. Limited Liability Companies(LLGJ or Limited Liability partaerahips(LLP)with no employ
am not required to carry workers,compensation insurance. if an LLC or LLP does have
members or policy
iDepartment of Industrial
employees,•policy is roquirod Be advised that this affidavit may be signadsubmitted to the the affidavit.
Accidents for confirmation of insurance coverages Ake s oure r license is being requested, sot the Departmen of should
be returned to the city or town that the application for the permit
Industrial Accidents. Should you have any questions regarding the law or if you aid required to obtain a workers'
all the Department at the number listed below. Self-insured companies should enter their
compensation policy.Place
self-insurance license number on the line.
City or Town Ortkisk
plcau be sure that the affidavit is complete"artd printed 1i sibly"Tire`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.
ln,wise be sure to till in the permiulicense number which will be used as a reference number. In addition,an applicant
thrt mutt submit multiple Perm applications in any given year,need only submit one affidavit indicating current
ult
policy information ult(if necessary)and under"lob 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 eats
year. Where 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 ere')said Person is NOT required to complete this affidavit
he Oi rice of lnvesti,. s would Cure to thank you in advance for your cooperation and should you have any questions,
please Ju not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Od[eo of lovestlptlons
600 Washin69oe Sitter
Boom MA 02111
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
nevi>eJ 3-2G-US www.masa.gov/dia
CITY OF SALEM
- PUBLIC PROPRERTY -
DEPARTNONT
,.v.•a.r .e.+,�
>L�... l3C'L�eN::OraSatta;T•&WN.WAvlrt w atlb"'lr.
T71c:rD�t+�riaf•f•�:C 9t�J�6lW
Construcdon Debris Disposst Affidavit
(requiml ra an deamaidan and genovation wont)
In=wdame with the sixdt edition of dw State Buildian Cod%7So CNIA section 111.11
pebria,w A dw provisions of MCM c A$ 54
guild1%P rmit p - _ is issued with thA condition shot the debris mmddns Plum
this wait shall be disposed of in a properly neansed wam disposal facility as dented by WL e
1L1.S15"
The debris will be transported by:
_ moms of ho.IM
rhe:k-bds will be disposed orin :
..d
'a EYI'Y-OF
PUBLIC PROPERTY
DEPARTMENT
KL%...nORRUAL
M74 M..ALf7►746MN
A_*PLCA1'I IN FOR �IMVA30M CAMSMUCTURL
DLNOL>'*10M. OR CAANCS OF Cis OR OCCLn&rlrv_ FOR ANY >P�rr�rrrl�
�JC7'C�t OR B>L�>R�
1.�SfTR INFORMATION
Loeadon Now tivYdr
--
�/ Svtitiv6-2 /�1� -
Prooary inkxalad Inac Can watlon Area YM Hiabrb OlaMlot YM
2.11 OWNERNNIP INFORand
MATION
7.1 Owner of L _
Narrw: cS✓L /Cot
Addresc
So R�
Taw ? `f S' - d S-
&aa c.OMPLETR THIS SECTION FOR WORK IN E U@nNo BUILDINGS ONLY
Addition FjdW g
Renovallon Number of Stories Renovated
Change in Use Now
DemoGMon Existing
� �
construction or renovation Area per floor a Renovated
of existing building New
9dat Description of Proposed Work:
1�eA4--06 V6 4 Xf Sr,
--- - ---Mail Permit to. ' -
What it to cum"use of the auk**?
Malarial of auidM+4? A)O 0 r) it dwdlni,hOW mar"units?
WE do auidrtfi Conlbrm to LOW? Asb«tos?
Ard"ca Nanta
jes Narna i 767�5T Li0 Z7ye
Addrw and pna,a�� �.iyiV�L �T D
Conatuotlon supanims ucwuo s D&8'n S9 MIC ^• /D�2 79 8
EatYnwe Coat a 3 b .`� Panty F«Cal gbft
ParrnR Faa i Esfts ad Coat X i7litOOO ReeWw"
___ . - --- - - - EalMnabd Coat X i111i1C00 ConwnardaL -- ---An/lddl Wnd S&OO IS added n an
Admhiatrativa dwpa.
Matra sun that an Mlds an PropartY and Wg"writtan to avoid dNaya in
Tha wxmm W+ad do"harg"apply for a Build ft build to
apaoifiaftm $Wad undw PAY Of P-MOr"Y
oat* 7-07
�I
s �r