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CHRISTOPOHNSONGROUP " .
3 ELM PL HER M O
ONAC -
fi" MARSLEHEAD MA 01945 �o
Dep"y A dministrn for
'.A, r�lF¢ Z/Jb)IL)IldHdf b�..�'!•GIIJJ![C/t( t�
' aL�
L. ill BOARD OF BUILDING f .,�t
{ License: CONSTRUCTION
[`- Number: CS 013075 3
' > Birthdate: 10/26/1954
Expires:,10/26/2007 'Y f
Restricted: 00
CHRISTOPHER A.MONACO -
3 ELM PLACE
MARBLEHEAD, MA 01945
Commissioner �.-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
A Ix1Ri(RI EY DRISCLA-L
MAYOR 120-WASHING fON STREET•SALEM,MASIACi n:urrfs G1979
Te> 979-743-9595 • FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Arivilicant Information Please Print Le ibly
Name(Bucilxss/organizatiorVinndividual): '
Address: 3 zezr / '-11d // / 9
City/Statc/Zip: 1' ne #: �Cl / v�
Arc nu an employer? Check t appropriate box: 'Type of project(required):
I. 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
ennployces(full and/or part-tire).` have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. wilding addition
I No workers'comp. insurance 5. ❑ 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 1 1.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, S I(4),and we have no I2.❑ Roof repairs
insurance red.i re w t crnployees. (No workers'
q ) comp. insurance required.) 13.�Other
'Ally upplicam that checks box#I must also lilt out the.wclion W-uw showing their workm compensation pulicy information.
'I lomvuwm;rs who submil this affidavit indicating I"are doing all work and then hire outside cummeton most aubmii a new affidavit indicating such.
;C.ommctun that check this box must anxhed an additional sheet showing the name of the subcontractors and their workers'comp.plicy inflammation.
/an+ can employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:. __._-_.-_.-.
Policy 4 or Self-ins. Lie. #: _. _— Expiration Date:
Job Site Addresszs— r --- - � City/State/Zip:
Attach a copy of the workers' compensation policy 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 m 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 slutcment may be forwarded to the Office of
hnvcsligations ul'thu DIAL for insurance coverage verification.
/do hereby c 6fy un.ler th ai �naft - «ry uujpJ the '+f n lion provided above is true and correct.
Sic:nalurl:. /t5p,- //� C W Data 7 V�
Ph!rrc is 7C/ ltf./ `"? C606
Official use only. Do not write in this area,to be cumpleted by city or rown official.
City or Town: _ Permit/License#____
-Issuing Authority (circle one): -_-
l. Board of Ilealth 2. Building Department 3.Cityffonvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I
Contact Person: ____._. _. . Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as"...every person in the service of another tinder any contract of hire,
express or implied, oral or written."
:1n 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 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. IvIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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 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.
111ease 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 pennitilicense 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 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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
1'110 Office of Investigations would like to drank 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
office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-20-05 www.mass.gov/dia
CITY OF SALEM
I PUBLIC PROPRERTY
DEPARTMENT
\IAYt�ti 12C W.WffN';:JNS:REET •SALL%1. SIAYUCku YL1T50.9/C
Tta:97&7ii-1595 #F.":97tl•7-W,9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CbiR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ _ 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 V1GL c
111. S 150A.
The debris will be transported by:
�J
wamc of h r)
I'lie debris will be disposed of in
Mame of facility)-�
data.
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EITrOFgXLEA ~ -
PUBLIC PROPERTY
DEPARTMENT
N..aa 130 WA*UNGWW snM•s sd n01970
Tft.97L7aS4M.FAX M-7404M
APPLICATION FOR TILE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CAANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUII.DLNG
1.0 SITE INFORMATION
Location Name: 2
Properly - --
Property is looted in a;corwervation Arse Y/N Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 owner of Land
Name.Address:
Telephone:
3.000MPLETE THIS SECTION FOR WORK IN ECSTrrvrs BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
86ef Description of Proposed Work:
y '
� P 2 ff
Mail Permit to: _ -
What is the current use of the Building?
Material of Building? it dwelling.how many units? _
Wis the Building Conform to Law? Asbestos?
Arehit ds Name
Address and Phone ( 1
Mechanles Name
Address and Phone
Construction Supervisors L;cs�ns�e C�S HIC Registration N //D /
Estimated Cost of Project$- < VL PWM FN Cakx+l m
Permit Fee S Estlmated Cost X S7IS1000 Residential
Estimated Cost XS11/51000Commercial------__-_
An Additional $5.00 is added as an
Administrative charge.
Male 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 71T C
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