14 WHALERS LN - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
S I]tbi(K117Y DRISCOLL
\'IAYOR 12^.WnsHINV lox STREET ♦SALEM,MASSACI Res}':1-rSG197.
1t1-978-745-9595 • FAX:978-740.9846 _
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
aMe (Hucincss/Orpanization/Individual): M� IJ fls-`+ l at�iRNc�a�
Address: _7/o__) x/,) dB VYL rQ,
/xrr K�-d&, x3 - M 0189 ? Phoneik ��� ' 31Z- " OAS Z
C ity,Statrr�'%ip: ��
:kre you an employer? Check the appropriate box: 'Type of project(required):
!.❑ i am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction
employees full and/or part-time).* have hired the sub-contractors
( P Remodeling
_ I nm a sole proprietor or Banner_ listed on the attached sheet. t ��
ship and have no einployccs These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. [:] Building addition
To workers'coin insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 1 I.❑ Plumbing repairs or additions
3.❑ I ant a hmneowner doing all work g P P'
myself [Now'orkers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance reqired.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant shut checks box tit must also rill out the section Wow showing their workers'compensation policy information-
T ilomeuwocrs who submit this affidavit indicating they arc doing all work and Own him omside cwumetors must submit a new affidavit indicating such.
-Coatracwrs that check this box must adachcd an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am mr employer that lc providing workers'compensation insurar+ee fin•o+y employees. Below is the policy and job site
iuforniation.Policy 4 or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/Stale/Zip:
Attach it 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
Fine 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of tht: DIA for insurance coverage verification.
/r!n or
Ic • y •rlif der the pa7andpenallics afperjury that the information provided above is tare and correct.
Sicntuuret Datc:
Official use only. Do not write in this area, to be completed by city or lown official.
City or Town: .-_--_____-- Permit/License k ,_-----._.... .. .-_---
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ___--- _-- .- _.__-- Phone th
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ,
Pursuant to this statute,an einploree 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,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 he 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-contractor(s)name(s), address(es)and phone nuniber(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 confinnation 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 time 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.
Please be sure to fill in the permidlicerise 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 fixture 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
'I he Office 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
1 ' I PUBLIC PROPRERTY
DEPARTMENT
MAYOK 12C W.%St IING'.DNSCREET •SALIA.%C*SSACtll iLll"S319/C
Tn:97&74i-9i95 * F.aX:978.74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C11IR section 111.5
Debris,and the provisions of M. GL c 40, S 54;
Building Permit # _ _ -_ is issued with the condition that the debris resulting from
di
this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
l 11.S 1.50A.
The debris will be transported by:
_J `G NSj8�t1GTSQ�
(name of hauler)
The debris will be disposed of in
I�oVAN�L1 N�/� �I �\JSle'MS � RIJUEVL, : I12 /.�5�¢fR— STgT-10N
(name of facility)
laddres. of tacLty� .
]i_Catu, lC[Ill{I d(l O.IC 1'l[ --_—_-
l 7
.iatr -- -
PUBLIC PROPERTY
DEPARTNIF��iT
1:maws"DRLSCaYL
HAYM 130 WASH PW"bl1 JntAiw 4 rz,lal:st,,ls 01970
Tm-M745.959S a PnS M7149"6
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nams: Building:
--- -- Property Address _ -- -
Property is located in a;Conservation Area YIN Historic Olabld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: LAWR.iLNGE. (r dt-t, N
Address:
I U Nn(-�,(Z,1�: L-Wu P& 11A 014 W
Telephone: - sq S S 0
3.0 COMPLETE THIS SECTION FOR WORK IN EX1QT1uG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description
Description of Proposed Work:
I��r,avAt� vF £�CiS?; NCr P{yTzO dsO-b/LS J> >J p
(C£PLacF K�Ns W�-rH JJbc,� uNL�S , �oL-)1;S TN�ALL
Mail Permit to: _ -
What is the current use of the Building? �J� 7 d , I C.617 C/C)
Material of Building? (✓a o d If dwelling.how many units?
Will the Building Conform to Law? l%Ifs Asbestos?
Architecfs Name tfa C
Address and Phone IV R ( )
Mechanic's Name 0 n
Address and Phone A
Construction Supervisors License# C S Off 19 7 /HIC Registration# /�7
Estimated Cost of Project i 0 06 Permit Fee Calculation
Permit Fee S Estimated Cost X$7/111000 Residential
-- -- - - - - _ - Estimated CostX$il/s1000 COnwnwclat=- ------- --
An Additional $5.00 Is added as an
f
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 X
x- -
specifications. Signed under penalty of perjury a
Date
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