18 SYMONDS ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
XlXl11i R1.r.Y URISCOU
MA Yon l20 WASHING 1ON STREET •SALEM,MASSACrn;sl:-ffS 01970
'ILL:978-745-9595 0 Fax:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �J� /f Please Print Leeibiv
Name (Bttsiness/OrganizatioNlndividuul): 721G Q�� ,,^'/�
Address:_ � � , s �tLktd'
City/Stare/Zip:, 2' ✓P�. (Z1SiS' Phone 1c22 96k,)
Are you an employer! Check the appropriate box: 'rype of project(required):
1.❑ m a employer with 4. ❑ I am a general contractor and 1 6 ❑ New construction
em to yces full and/or putL-tint!).• have hired the sub-contractors
2.
P > ( P 7. ❑ Remodeling
I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
i ❑ We are a corporation and its
I No workers' comp. nsurance 10.❑ Electrical repairs or additions
required.] officers have exercised their _
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, §I(4),and we have no 12.❑ Roof repairs
insurance required.) r employees. (No workers' 13.❑ Other
comp. insurance required.]
-Any applicant that checks box ill must also fill out the uclion below showing their workers'cumpemtion policy information.
T llumowm:rs who submit this affidavit indicating they are doing all work and then hire outside cotumclors must submit a new al'Gdavil indicating such.
�G,mncnrrs that check this box must attached an additional shin showing the name of the sub-contractors and their workers'comp.policy information.
I our an employer that ix providing workers'compcncadon insurance for my employees. Below is the policy and job site
information.
---
Policy 4 or Self-ins. Lic.B: —_.___......._._-____ Expiration Date:
Job Site Address: City/State/Zip:
:\ttuch a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I'ailure w secure coverage as required under Section 25A of MGL c. 152 call lead to the imposition of criminal penalties of a
tine up 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
luvesligalions of the DIA for insurance coverage verification.
l do hereby ccrti ul derr the pa' uul peuakies of perjury that the information provided above is true and correct.
Srenatnfet /�i�/�" DaIC: r ZZ
PhunC�:
Official use only. Do stair 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.Cilylfolvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01tier
Contact Person: Phone #:
Information and Instructions
tblassachusetts 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."
Art 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 otter 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 licepsing.agency shall withhold_the issuance or
renewal of a license or permit to operate a business or)to�codstruct 1.hiiildings i&tbc'com nonwealth for any
applicant who has,not producedaccept'able evidence of compliance with the insurance coverage required."
Additionally,MGL chapter I52, §25C(7)states"Neither the comm6t4calti nor aiiyof'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 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 continuation 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 he 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 permit/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[he
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 bun leaves etc.)said person is NOT required to complete this affidavit.
The Office ofl live stigations 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 e
r ti ' oDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax #617-727-7749
www.mass.gov/dia
CITY OF SALEM
ovi6
PUBLIC PROPRERTY
DEPARTMENT
.CL\L':h X I.CY 1'R;1CUII-
MAYo t I2C W.\91tVl-,i OD1 SYREET •SAL r]t, MASiAGM.ILI-I S 019;^-
TEI.:978•745-9595 . F..x:978a4C-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 i 11.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # _ ._p __ is issued with the condition that the debris resulting from
di this work shall be sposed of in a roperly licensed waste disposal facility as defined by vIGL c
1l1. S 150A.
The debris will be transported by:
(smme of hauler)
I'lie debris will be disposed of in
(name of facility)
. . . ..._ .__ l�Ilr "I tall�
11_C1ILLC2 )f i)cr1111t "PI),Iclat
1ate
CrrrOFzyXLEN
PUBLIC PROPERTY
DEPARTMENT
130WA*UNG >MSbr 6 •SMAiKM. AUACft5k li01970
TM-971L7JS-9S9S•FAzw6.7i49W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEbIOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: SuildtrW
SA e-&- "1 1,4A
Ropsrty is located to a;Conservation Area YIN IV Historic District YIN ^�
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land qN�.4 3A G Loi,i 5l<r
Name: rn/n/q -1.4GL01 15 K 1
Address: / 5 ` t,4ONoS Si
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use New
Demolition ✓ Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
� iou SN CI-17"l/e-1 .zlv 19AC/( of 1-40v5E ,
�/-1�1'"l/V�� 1'S /�/O n/� f=7✓T✓G 1 TOn/T�V G
-- - — Mail Permit to:
What is the current use of the Building? /J we-L.LvV A.
,i
Material of Building? p D If dwelling,how many units?
Will the Building Conform to Law? `«� Asbestos? ND
-
Archited's Name
Address and Phone I )
Medtanic's Name plc /ri—D tcw n-f
Address and Phone,
CorWruotim Supervisors LIcwas HIC Registration 5
Estimated Cost Of�Pro�je/dl i Permit Fee CalcuWM
Permit Fee S Estimated Cost X$7/51000 Residential
Es*m tsd Cost x$111111000 Commwclal = ---An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build bove stated
G G
specifications. Signed under penalty of perjury X /'
Date
U a ti
a