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13 SURREY RD - BUILDING INSPECTION (3) CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT FIUflF R[F.Y URIX:ULL T(AY(sit I2C WASMt.NGfONSTRt2'T a SAtEM.MAaAansrrtsOl9T Ti.L:978-745.9595 •FAX:976.74C,9s46 Workers' Compensation Insurance Affidavit: Builders/Contracton/Electricfans/Plumben Apr►licant Information Please Print Leeibly Name tauaii :wOrganizatioNlndividual): Address: -A/ tcw IC4,60 C/— City/Stare/zip: 21e1W . A6 5 S Phone #: -DA —7 Arc_you mployer?Check the rppropriute box: Type of project(required): I. am art with z 4. ❑ I am a general contractor and 1 6, ❑ New construction employees(full and/or part-tine).' have hired the sub-cuntractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet r 7. ❑ Remodeling k ship and have no cinployc" These sub-contractors have S. ❑Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'cutup. 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 right of exemption per MGL I L❑ Plumbing repairs or additions Ilj myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other I comp. insurance required.] 'Any applicant that chucks box 91 must alto tiff nut the section buluw showing their wurkms'compentmion policy inium a man. '1 Wnwuwnan who submit thin oftldovit indicating that are doing all work and than hire outside cantmcaan,mutt out nit a new affidavit indicting such. Canttxmrs that chsk this bon must attached an addiliomd sheer showing the name of tho sub-contrwm and their wurken'comp.policy information. I am an easployer that Is providing workers'compensadon hssurance for xsy employees, Below is the pin/icy and fob site 4 Ltjorsnatiom [/ Insurance Company Name: �r J re 4,!1_ _ _ . / [ l/4 AIt Vol icy#or Sclf--ins. Lic.n: /�/G 6' a7077._- �frdiion Date: S c� - - 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 uf.IGL c. 152 can lead to the imposition of criminal penalties of a zinc op to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the ODice of lug csngatiuns uf the DIA for insurance coverage v xitication. /Ju hereby certify tit er the pains nJ r nit'• uj rrjary that File isrfurmation provided above is tress red correct m;uo". _ Date, u i / Official ase only. Do not write in this area,lobe cone plefed by city or town oJJic/al City or'rown: _ Permit/License Y Issuing Authurily (circle one): 1. Board of Ilealth 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Coutaet Person: __ Phone #: l Information and Instructions r> r,lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for Their employees. pursuant suant to this statute,an employe is defined as"...every person in the service of another under any contract of hire. express or implied,oral or written." eu pio)wr 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,p+utactsiup,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." b1GL chapter 152, §25C(6)also states that"every state or local liceusing agency shall withhold the issuance or renewal of alicense 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 152, §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)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,ate 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 litre. City or Town Officisht 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 till in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicetsse 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 tilled 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 burn leaves etc.)said person is NOT required to complete this affidavit. l'hc Ottice of investigations 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 O e of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax p 617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT TV:9M745-')M •FAA 071-74G9844 Construction Debris Disposa[ Affidavit (required for all demolition and renovation work) In accordance w ith the sixth edition of the State Building Code, 7S0 Ci`1R section 111.3 Debris,and the provisions of M. GL c 40. S 54, Building Permit N _ . _ 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 130A. The debris will be transported by: . /f T Inamealhaulty fhedcbris will be disposed of in &S,-/t-- tnamr of faalhtl S �le/1'I SSG �/l✓✓✓� tS.a,ly) . 414 - What is the Current use of the Building? Material of Building? If dwelling. how many units? Asbestos? Win the Building Conform to law? AmWdeds Name Address and Phone Mechanie'a Name t Address and Phone /S{ r� ao `'L Construction Supervisors license S O 7 /6 J ) HIC Registration# O Estimated Coat of Projed S permit Fee Calculation Permit Fee: Estimated Cost X$7/111000 Residential Estimated Cost X$11/$1000 Commercial-- An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the abov to specifications. Signed under penalty Of perjury Date 1 6' I N �MM v n �1 96 t7 V 6 L 4 i 1 - PUBLIC PROPERTY DEPARTMENT NIMSERLLY DRISCO L N..Yoa 130 WwvuNGsw s T SJMAK N.UswNLserrs 01970 TEL—9'.L743-IM*FAX:M740.9W APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY VaSTINGI STRUCTURE OR BUILDIN . 1.0 SITE INFORMATION Location Nana: Building: ---— - Property Address ------- - - ---- -- — -- Property Is located In a; Conservation Arse Y/N Hlstaft District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Now Demolition Existing Approximate year of Area per floor (st) Renovated construction or renovation of existing building New Brief Description of Proposed Work: -- ---- -------Mail Permit to: En-�t Or PUB PROPERTY DEPART11dENT KI%OFJ"DRISUri1 %UYaa 120 WAuuNGTm b'n Lmr*SA K LsL-rM 01970 TEL M743_9S93•FNe 97L740. M 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:��_--. -- -_---- - Property is klcated in a;Conservation Arse Y/N Istorio Dlsirkkx YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: © h Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXIS1MG 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 !wilding New Brie[Description of Proposed Work: r ------Mail Permit to: C 00`-1 L�O, Yh rw 6eve5io ,¢vcl— -- � a>r What is the current use of the Building? Material of Building? Ifdwelling,how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone l ) Mechanids Name Address and Phone Constructlon Supervisors License 0 HIC Registration 0 Estimated Cost of Project i Permit Fee Cak,uladon Permit Fee i Estimated Cost X$71$1000 Residential Estimated CostX i11/$1000 Commerciei` An Additional $5.00 is added as an Administrable charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury Date of � N 01 " 14� a > `d s a 96 a - -- _