257 WASHINGTON ST - BUILDING INSPECTION (4) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:tstnrnter urtfst:snl
MAyc tt IZr WAslew'role STREET*SALEM.WAscvtl n`Wl-ln 0197.^.
Thi_979-743-9595 4 FAX:97s-74069946
Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
NamC tdu.iiicss/OrganintioNlndividwi)::a. L , 1 4c \ d'
Address: Z s / (linos �, •t`h pis ��.
City/Stawdzip: �n..,� ti� �j/97�) Phone a: �76 7V'f 2s�_`
It re ou an employer?Cheek the appropriate box- 'Type of project(required):
I.iy1 am a employer with 13 4. ❑ 1 am a general comractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole propricuw or partner- listed on the attached sheet : 7. ❑ Remodeling
ship and have no employtxa - Thee sub coholacwrs have 11. ❑ Demolition
working for tin: in any capacity. workers'comp, insurance. q, ❑ building addition
[no workers'comp. insurance S. ❑ 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 11.0 Plumbing repairs or additions
myself.(No workers' comp. c. 152,§1(4),and we have no 12.,...,(Roof repairs
insurance required.) t umployees. (No workers' 13.t�1 Other
comp. insne a requirod.J
•An)applicaW tht ehxka bur el must also fill as fie suction MOW showioa chair wwkwa'ewupensatiun pWiry iofurna ii'
'1 t so ,wn who subsoil this affidavit indicuina ems,am twiny 90 work and then him outside coetraciom most suhnir anew andavil inaic,llna such.
:Coattacttas that chock the bon mum anached an addilio W sheet showing the nwo of tlr>vii-wNrutom and their workem'comp.policy inferesatitm.
I oars an emplayer that is providing workers'compensadon Ltsarance for any employees. Below is the policy and job site
iuformuri at /D L
Insurance Company Name: «4JQ��-c5
Policy 4 or Sclr--ins. Lie. N:_X n (A 13 10 73 W D3 67 (V!7 Expiration Date:
Job Site Address: X59 WfASk A,,r T/rt_57' City/Stawizip: .PC, (w7)
Attach a copy of the workers'comps ation policy declaration page(showing the policy number and expiration date).
Failure to wcurc coverage as required under Section 25A of.%,IGL c. 152 can lead to the imposition of criminal penalties of a
f nc up to S1,500.00 and/or one-year imprisonment,as well as civil pcnallics in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this xiawasent may be forwarded to the 0111ce of
Int•uangaautts of the DIA for insurance covera;e ecritication.
I do hereby cerlify and rV pains and pen/uhi/ev fperjary that the information provided above is sae and correcL
tii,�tuur n{ `i,/ b/c�(.fGr/ I):rte• �
g ,.. .. EE//ll Illl SSA
f Off vial use only. Do not wrire in thin area,to be coeipleted by city or town ofjiriai
City or•town: _-. PermiVI.icense
Issuing Authority(circle one):
1. board of health 1. building Department 3. Cityifo in Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C.aulact Person: _ Phone p:
Information and Instructions
,r
Massachusetts General Laws chapter 132 enquires all employers to provide workers' compensation for their emptoyeea.'
Pursuant to this statute,an employee is defined as"...every person in the service of another order any contract of him
express or implied,oral or written'
An employer is defined as"an individual.Partltaab*aetociauGO-corporation or other legal entity,or any two or more
and including the le representatives of a deceased employer,or the
re the foregoing engaged in a joint enterprise. u�li »� ees. However the
entity, t loy
recover or trustee of ao individual•prraenlup,association or other legal mY• cep
owner of a dwel ' a house having not mote than three apartments and who resides therein,or the occupant of the
Vo
Swelling 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.-
AtGL chapter i 32,§23C(6)also states that"every state or local licensing agency shag withhold the isstsuce or
renewal of a Iteense or permit to operate a business or to construct buildings In the commoawesltb for say
applkaut wbo bag not produce aeeeptab a avidame of compliance witb the insurance coverage required."
Additionally,MGL chapter 132, $25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
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enter into any contract for the performance of public work until acceptable evidence of compliance w ith the insurance
requirements of this chapter have been presented to the contracting authority.-
Applicants
Please till out the workers'compensation al%davitcompletely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nante(s),address(e)and Phone aumber(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employee other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP doe have
employee,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 dale 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 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 Offieteb
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.
Mouse be sure to till in the p arnit/licentse 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 now 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
(i.e.a dog license or permit to bum leaves etc.)said person is NIOT required to complete this affidavit.
1'he Oftiec of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
pleas du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
On%*of Isvesd aden
6W Washington Street
Boston,MA 02111
Tel. k 617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised i-26-03 . www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I
To.971445-45" •fmt:97i Q-9e41
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CNIR section t 11.5
Debris.u►d the provisions of M. GL c 40. S 54;
Building Permit N _ . _ is issued with the condition that the debris resulting from
f in a property licensed waste disposal facility as defined MtGL e
this week shall be disposed o D DAY Po tY by
I It.S 150A.
The debris will be transported by:
14 f f—
mme o[hauler
JK- )
the debris will be disposed of in
� 060.
-P.rz L
h�+me of fullity)
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i,..A:rcx. .�f YaeiLly)
EITXOF _ _
PUBLIC PROPERTY
DEPAR'I14IENT
yubr,,U&ssAaicsti-rs 01970
TEL-978-745-9S95♦FAx:97L740.""
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION OR CHANGEOF S OR OC ANCY FOR ANY EMI TIN
U E CUP EMS TING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nams: 257 Building:
Property - -- — - --- -- -- -- - -- _ —_
I
Property kt boated in a;Conservation Area Y/N nl o HlstoAc Dist ict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: y
r- llS i>> Eriivre.+ r P�
Address;
S a"k S Z �f � D 5 70
Telephone: T76 3 2
3.0 COMPLETE THIS SECTION FOR WORK IN�NG BUILDINGS ONLY
Addition Existing L /
T Sew.
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of S Area per floor (sf) Renovated
construction or renovation
of existing building I New
9aef Description of`Proposed Work:
Mail Permit to: --
What is the current use of the Building?
Material of Building? If dwelling.how many units? (8
Wig the Building Conform to Law? es Asbestos?
Architect's Name _
Address and Phone ( )
Mechanic's Name �E l vl e K,g
Address and Phones
Construction Supervisors License 0 2 35� HIC Registration 0
Estimated Cost of Project i `sODO Permit Fee CalaLW_M
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated CostX 511lS1000 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 above stated
specifications. Signed under penalty of perjury
Date n
• i
INN
.14
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