15 WARREN ST - BUILDING INSPECTION CITY OF SALEM
D� PUBLIC PROPRERTY
DEPARTUEM
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Construction Debris Disposst Affidavit
(requital for all denalition and renovation worts)
In aaonlaace with the sixth edition of the State Huildin=Cods. 790 Culls section 111.3
lkbris.&a the provisions of M. GL c 40.S A
staiidiss Permit 0 - _ is imudd with the condition that the debris rmddns ham
this work shall be disposed of in a property licensed wtute disposal tbeility as defined by vlGL c
II1. 31l0A.
The debris will be transported by:
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rho&-bris wilt be disposed of in
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Myatt 12CW^9i A—.rC tSneeraSALE*bLAsAaaytrno1970
'fkL 976•74S-"" a FAX:97L740.9946
Workers' Compensation Insurance AflldaviC Builders/Contractors/Electridons/PMmben
Analicant Information Q Please Print Leeibly
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Address: 6
City/smte/zip:
Are you an empbyort Cheek the appropriate boa of project
I.❑ 1 am a employer with 4. ❑ 1 am a gcm•ral contractor and( 6 Pe (required):
loycea(full and/or part-time).* have hired the sub-contractorsb�'�❑K �r�o�Construct
ion
1 am a sole proprietor or parer. lured on the attached sleet. t yes wa"'oliag
ship and have no employees Them wbcatrractots have a. ❑Demolition
working for me in any capacity. workera'comp.insurance, q, ❑ Building addition
(too corkers'camp. insurance S. ❑ We am a corporation and its !0.❑Electrical repairs or additions
required) omega have examixed their
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.J1(4).and we have no 12.0 Roof repairs
insurance roquired J t employees. [No woken' 13.❑Other
comp. insurance requirtxLJ
-Ally:.pelican tlrs chacka boa et art also rdl w em aectiae bvbw.Iwwioa tacit watas'tarapaaedw pdicy ienMmation.
'Ituequwtatn who sonnet aria atlldavit indkatuta Noy am Juina tit wok■ad fatal him aeside commcwm marl.uhmis a new atadevit inJiaeina aw4,.
;Contnatwa thm chuck this bast nut aeaotatd as additioeal d`rt sllowity Ne ntoe al,ate tee romaci m and their"duirs'cap.policy utbrmantta.
1101111111111
I am on employer that Is providing worker.'rompeasadon huaranee/ar my employees Below is tht policy andlob site
lajormadmis.
Insurance Company Namr.
Policy Al or Sclf-its. Lie.0: _.. _--- Expiration Date:
Job Site Address: CilyistawZip:
attach a copy of the workers'compensatlon policy declaration page(showing the policy number and expiration date).
Failure to wcum coverage as required wider Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,ae well as civil pcnallics in the form of a STOP WORK ORDER sod a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statceunt may be forwarded to the Office of
luc.,ugmuaut of du DIA for insurance coverage reriftutiun.
I do hereby re �411 , �if��rluy that the itr�orarwion provided above is tine cad correct.
Ci•:rrtur- p C�—
row
F0ffWafwzfon1A only, Do trial,wrlfe/a fhb area.to be rump/eldbydryor/own ofJlelid
n: Permidl.leeaseurity (circle aivil-Ilealth 2. Building Dcparnncnt 3.City/fowa Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: _ Phone p•
Information and Instructions
Massachusetts Gctteral Laws chapter 132 tequirtrs all employers to provide workers'compensation for dWiretttpbytea
Pursuant to this statue.an eas<royte is defined as`...every person in the service of another under any contract of him
e%press or implied,oral or written"
aesoeiatiea6 corporation or other Icgal entity,or any two a more
AA espfeyw is detiaed es"m ia�tridttal.parnetship.
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
asaoeindoa or other legal entity.employing employees. However the
receiver a trustee g o individual.act
me the and who resides thereie,err the Occupant of the
owner of a dwelling hoofs having not mots thin three apartments
dwelling house of another who employs persons to do maintemance•construction or repair work om such dwelling house
or on the grounds or building appurtenant thereso shall not because of stseb employment be deemed to be an employer."
AtGL chapter 132.125C(6)also states that"every states or beat liceasbg agency shall withheld the lssumee or
renewal of•Been mit e or Per to operob a business at to construct bttildlags Is the commoawtsM(Or my
appassant who has ant produced accept"evidence of compliance wit►the insurance coverage required."
Additionally.MGL chapter 152.h23CM stave"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performs=*of public work until acceptable evidence of compliance with the insurance
requiremeats of this chapter have been presented to the contracting authority."
Applicamu
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply subeommeral(s)namc(s),address(es)and phone number(s)along with their cortificate(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 au LLC or LLP does have
employees.a policy is required. Be advised that this affidsvit maybe submitted to the Deparmment of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The atrdavit 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 low 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 Oeklab
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 pormit/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 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 penult not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
fha Otii,x of Investigations would Glee to thank you in advance for your cooperation and should you have any questions,
plcuse do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of IadusuW Accidents
Oleet of favaatlpdow
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
2evi.sed 3-26-05 www.mass.gov/dia
1 FEPAR
OPPPTMENT
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WtlOa 130 WAU4MGTnw 5rfssr•SJUAM4 WAsuaas►'f'M 01970
11m M7459SU 0 FAX M74606%
APPLICATION FOR THE REPAIR RENOYAT[ON_ CONST atrtr_rr[>tN_
DE.riOLIMN.OR CHANGE OF USt OR OCCUPANCY, FOR ANY EXISMG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Names 4. Buildng;
---- -
piny --- - - - - - -.. _.. --- - ------- -- -- - —
ft*w r ie Wcdsd in s;Caww dm Ama YM MW"Ic Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: G �rz �r2GL
Address:
Teleph .
3.0 COMPLETE THIS SECTION FOR WORK IN DINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New.
Demolition Existing
Approximate year of Area per floor NO Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work:
----- ---Mail Permit to:
• ,S
What is the cxurent use of the Building? � � {
hAaterW of Buldkg? A-29—n Z if dwelling.how many unit? 3-
Will the 8ui&V Conform to Law? Asbestos?
ArchitcYs Name
Addmaa and Phone t
MectwWs Name
Address and Phone C '-106;0- 4iu
construction Supervisor Li,..a D!'79�7 Z HIC R"WJstlon d f Q9205
E.Watd Cod of ft0i" 200 Permit Fes Calwttlort
3>>t7d a Permit Fee S Esth aced Cod X$7/51000 Residential
-- - - Estimated Cod X:41/it00A Commmetal---- - -- - .
An Additlonal$5.00 Is added a.an
Administrable charge.
d�N Make sure thad all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building P build to a
u. bo sled
specftdlo Signed under penalty of perJury
Date
71
44
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