26 WEATHERLY DR - BUILDING INSPECTION f'
CITY OF SALEM
K. PUBLIC PROPRERTY
DEPARTMENT
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MAY(xt 12C WAStuNIG folx STREET 4 SALEat,MASSACI a sh'rtS 0197�.
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) licant Information Please Print Le ibly
Name tBustiw%siOrganizatioNindividwi):
Address: _
CitylStareiZip: 0 ul.';(l R 0 2/)ZI'hone /t: /7-
Are,you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and[
s 6. ❑ New construction
employees(full antllur part-[irne).a have hired the sub-contractor
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7. ®Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their
10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l.(R Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Ally opplicara that checks box dl must also fill out the watan below showing their workers'cunipcitution polity imiirmatiu2
' I lommuwmn who suhmil this affidavit indicating they are cluing all work and then hire outside curam. 10n must oubmir a new afrdavit indicaing umh.
�Contmum that check that box must anached an additional Abel xhowing the nano of the sub-contraaots and their workon'comp.pilicy information.
l ain an employer that it providing workers'compensadon insurance for nny employees. Below is the policy and job site
iaforinaturn.
Insurance Company Name:_4�fry-x 7L./I t°/(/ ,_ ___
Policy#or Suif--ins. Lie. #: /_.._. _- __- - Expiration Date:
Job Site Address: � 6Je,G Vz `7 'A�7[-; City/Statei2ip: 36 ' tPir�--
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can 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. lie advised that a copy of this statement may be forwarded to the Office of
rut csngauons ul'thc DIA for insurar:ce coverage verification.
l da hereby certify tinder the tuts ml penu/tic fperjory that the informalion provided above is true and correct
Oatg, 7z4;:0/f 7
Phi me#:
Official use only. Do not write in this area,to be completed by city or town official.
cityor'rmrn: __ _, - -__ Permit/l.iccnse#__,__
Issuing Aulhurily (circle rate):
1. Board of Health 2. Building Department 3.Cityffotcn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions ro
Massachusetts 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."
An 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.associatioa 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."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license 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-contractors)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 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 inter their
self-insurance license number on the appropriate line.
City or Town Official
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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please 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 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 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Oilicc 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
Oftlee of Investizationa
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
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PUBLIC PROPRERTY
DEPARTMENT
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TO:978.7+5.1595 •F.%r:978.740-9846
Construction Debris Disposal affidavit
(required for all demolition alai renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5.
Debris, and the provisions of v1GL c 40, S 54;
Building Permit tt _ . ._ 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 M. GL c
l 11.S 1.50A.
The debris will be transported by:
— (r2ame of hauler),
l'he debris will be disposed of in
(u:unr of i�atltr)
R'.II I
PUBLIC PROPERTY L,y E-- o a3,,5-
DEPARTMENT y
MAYae
130 wA*UNCMW ft T �IAssAan:st�n 01970
Ta.M745-9S"•FAX 97L7469W
APPLICATION FOR REPAIR' REN®VATtON CONSTRUCTION
DEhu>Lr curl, OR CHANGE OF USE OR OCCUPANr,y FOR ANY E7CI3TING
STRU Ip OR BUILDINr
1.0 SITE INFORMATION
Location Nor W ..Z6 p [3wlding:
...-.-. .. .. .
Addreew-
e.tlm
Property is located in a:Conse don Area YIN Historic Dbtrlot YM
E
P INFORMATION
nd
3.000MPLETE THIS SECTION FOR WORK IN EXIATINrs BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation I
Of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of
the nBuilding?
`M� ��unitsT (�—
Of Building? if dweiun96 hw... .. an --- - - ..
Material P � ,�, c� Asbestos?
—
Will the Building Conform to Law?
p rchiteas Name
Address and Phone / o n o R 40-
Mechanids
PaIw�+em .
1 � LI'P e ram' C S �✓[.,�C /z�ls d 2 �—
Address anda % HIC Registration 0�
e Y
Construction Supervisors License 7 7Permit Fee Cakulalbn
Estimated Cost Of Pr°� `
Estimated Cost X i7/i1000 Residential
Permit Fee i Esd"ud@d Cost X i1 Vi1000 Gammercla4---- -An Additional $5.00 is added as an
Administrative aherge.
�I
Make sure that all fields are properly and legibly written to avoid delays in processing-
The undersigned does hereby apply fo►a Building Permit to build to th abov stated
specifications. Signed under penalty of perjury
Date 7
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