21 TURNER ST - BUILDING INSPECTION (4) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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W.\Ylnt 12C WAsimGYMSYaBT a SAUEW lLsstAs:le aa:ti-IN 01973
Tel:9y5•745.9M 4 FAX:9M.?40.9946
Workers' Compensadaa Insurance Affidavit: Builders!Contractors/Electrld*i /Plumbers
Applicant Information Please Print Leeibly
Name tlluaitstlOeynirationllttdtrtdtmp: ( s ee o� u c� n Jl
D p /la c, ,F
Address._ 7 �C J S c
City/St2tt•1Zip: /fir Iahonc#:_?7k 7-7/G'z4G
Are you an a®player?Cheek the appropriate bus: Type of project(required):
1.❑ 1 am a employes with 4. ❑ 1 am a Sets call contractor and 1
etnpluyces(full and/or p rt-tine).• have hired the avb•eumnctors 6. ❑New coniacuetion
2,M I am a sole proprietor or partner. listed on that attached sheet 1 7. ❑Remodeling
ship and have no etnploycol Thews sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp. insumace. 9. Q Building addition
(No workers'comp. insurance 5. ❑ We am a corporation and its 10,0 Electrical repairs oc additions
required.) officers have exercise!their
3.Q I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myselL(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t cmplaycas.(A'o workers, 13.Q Other
comp. insursnax:rt:quuel.]
-Ally:MhCl 4 tIM eh sso boa el most a4ar tea wa eta Maim bataw,aewioe tttwr warkq'aanpatetivw pdiuy ioaamWioq
'Ituini,it n wbe submis nua amdwit indiruby Noy ate da ng di wOt and t%=bhe amslde eammeaors aaw aulmk a osw atndavit indimina muck
-C, rat ttos the thedt Otis bw maw anaehoi m adduiaed AM%tawny tla runw of em robcontraaan and them workma•camp.polity intbano m
l um on employer that G provldln l workers'eompemaden Laurance for my employees Below Is the polity and Job site
informal"
Insurance Company Name: -c
Policy e or Sclr--ins. Lie.N: S�f� ofo _--- Expiration Date: ll U-7
Job Site Address: Z� /LrrylT/ !. It City/slater2ip: ilk..A A. 4/176
Artach a ctrpy of the workers' compensation policy declaration page(sbowing the policy number and expiration date).
Failure w wcum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ora
f me tip us 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. Ile advised that a copy of this statement may be forwarded to the Office of
Inr.augauntts ufthe DIA for iiNurance covcra.-e verification.
I da hereby certtf under the pains and�pe�nurlikss ufpperjury that the information provided above is truue7 and rorrecR
tie•:t:rti,r•: ---�-� \ 041W w -1• /
PN,ccJ: 2aj�Z
O/J&id art oa/p. Ike edr wrlre in rAh area,to be evAapkted by city or Iowa o/jleild
City or'fown: _.. Pcrmit/l.leettse N___
Issuing Aulhurity (circle one):
1. Iluard of health 2. Building Department 3.Civrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this st tune.an esspbyee is defined as`..every person in the service of another under any contract c1t hint,",
empress or implied,oral or writted"
An earpfeysr is defiaed as`an iadividusl,parmaes tip.association,corporation or other legal endry,or any two or more
of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.or the
assoctemos or outer legal entity,employing employees. However the
receiver ac tnsux of o individual,of inn shn a ' and who residue therein,of the occupant of the
owner of a dwelling house having not elites than three apattmeaes
dwelling house of another who employs persons to do maintenance,cuabtruction or repair work on such dwelling house
Oran the grounds or building appurtenant thereto shall not because of such employment be deemed to lot an employer."
MGL chapter 152.;25C(6)also states that"wary state or local licensing ageaey shall withheld tM issuance or
renewal of a license or permit to operate a business or to construct buildbW la the commoaweam for any
applicant who bat not produced acceptable evidence of coaptlance with the insurance coverage required"
Additionally.MGL chapter 15-4 425CM states"Neither the commonwealth onwealth not 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.tupply subaone actods)name(s).address(es)and phone aanber(s)along with their certificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partner,am 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 duce 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 Deparbmmt of
Industrial Aceideas. 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 atipro .sta line. —
City or Tows Off elab
Please be sure that site 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.
pluase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 maybe 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 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 burnt leaves ere.)said person is NOT required to complete this affidavit
I'hu Otti:c of Investigations would ac 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
OMM of lavestlpden
600 wathingtoa Sfrea
Boston. tit 02111
Tel. p 617-7274900 ext 406 or 1-977-MASSAFE
Fax S 617-727-7749
Revised 5-26-05 www.num.gov/ilia
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Y , 1
$T$EfiL+G--A 10 APPROVED BY T44E
LUSppXTPR pRWR TP A PERMT B,EWG GRANTED
CITY OF SALEM Date 7�d-��
No.
Ward
��FcrrnNe�'e Zoning District
Is Property Located in Location of
Building j
the Historic District? Yes_No
Is Property Located in /
the Conservation Area? Yes_No BUILDING
LLLL--
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof. Rer of, Install Siding, Construct Deck, Shed, Poo,
Repair eplac Other:
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: /
Owner's Name
Address & Phone al T,rr n LiC g78�
Architect's Name
Address & Phone
Mechanics Name 1 z
Address & Phone �1 n
Sclionl S� SalP.n�L cg�g� -��I - � aoG
What is the purpose of building? usi l P nog—
Material of building? t1 If a dwelling, for how many families?
Will building conform to law? 4 _Asbestos? 00 /� /I -
Estimated cost �S oa City license #
State License # CS I ��
g� � Home Improvement
`' Signa(dre of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
_ ►aeQ y �� g yllati
MAIL PERMIT TO: e r e Uf?
71) t3 SCA00i Sf
SalP.rn Pnq O/970
't
No. T
APPLICATION FOR
PERMIT TO
pp
LOCATION
PERMIT GRANTED
7ZO1 19
PROVED
INSPECT R OF BUILDINGS
I