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62 WHARF ST - BUILDING INSPECTION (3) , �D�'-O� �' CITY OF SALEM - - PUBLIC PROPRERTY ``� DEPARTMENT ��.�nr'Rcr.r uusu�u �t.�raa ►2C Vl�u�r.wraKSrneet�S� ti�l,l�fns�u.Y R aa:7'1\b197$ �rci vn�.sysys .F..x:v�.a+o.vx,s Wurken' Compen�adoe Iosunnee Aflidwit: BuildenlCoatracton/Eiectrielans/Plumben annticant Inform�tion Pieaxe Prtet Legiblv Vame i��a::,rcx��nrio�nuu���n: C�'.[_� �{��� ltitL�ld,,i� Gc*� �`� - .aad��: �f o LocV��LL S7,� ot�s c��y�sr��z�P: Lv�-kFt=ie7.D �-S' i�a: % ���'l � ,.�..� SG`- �Z 1�'� .�re y r�employrr'C�k tAe approprlaq pox �h�w o�P.o1«�lro9�d)_ 1. wa a cmpWyar wi�6 4. Q 1 am a ycn�yal toalractot and 1 6. �*'ew conYtruetioo ampluy�x,s(full uuYur p:wtinu).• hava hin�l chc aub-curuncwn 3.� 1 om a sok prapriccar or�r. lined oo d�e attached sshcet f 7. ❑Remodelia; xhip and have no omployvm� Ther wbea�vactoes haw 8. ❑ Dsmoli�on worlcina for me in mty cap;�city. worken'wmµ insiwnce. 9. � Buildins'rdditim (t�o waekrn'comp, insuranee S. � We ara a carporation wp1 ib !0. Elatries!r nquircd� o�cen have cxercirwJ their ❑ �p+in or additions 3.� 1 am a homeowna Join�all waic ri�l►t of exemption per MGL I l.Q Plumbing repain or acktitions myxlf.[Ko workcn'cump. c. 152,91(4).and we havc no l2.0 RuoFnpain insurance required.J � .mpbyees.[A'o workeq' 13.Q Otlatt comp inwran�tequirrd.] �n�ry.pplicatl Ido dkxW bot b� maO alw NU w iha aect�uo Ixbw d�D�ria`iArir wurtai'araPp�iu�Pu1i�y io�ia0 Il.rw�wnws wlw�u0ar1 Mir oflldpu ia0ka�b��Mry nt iWiy�di work W�Aos 41m oWfW�taaroebn muN�ubnL a n.w�alll�bvA ioJiaiiny w.�. �ta�unaw+qw cMxk d�it bas mu�u�xiwd yn addi�imd Wwn+4oriiy iEe nam of tlr a0.a�trxton aed�Atir WuAm'ta�0•i^�KY��nyMr. /uar un awpfoyer that 6 prov/ding workip'compenradoa Lu�ianec joi�ny enop/u}vex B�low!r tht pu/!ry unJ fob stfe --— -iu/'wr�u�fow. - - - - ... ... - - -� - .. .. _.m. ._.�«...,... Incurrnce Company Name: -- ._. - -- -- Poiicy p ix Seif-in�. Lic.M: Expirrnon Date: J�b�itc AdJrcax: �Od. WI�+��C� � .. .. _--- . CilyiSWtuZip:_._ J '7rLL'��' �'I I7 S S �nach r eupy of�h�worken•compcnaaHoa pollcy Jeclar�tlon pa�t(s6owlnR the policy numbcr and c:piratlun date} I�ri luro w x:cure co�errQe as requireJ un�kr Sec:�ion 33A uf�tGL a. 132 eau lead ro the imposition oteriminsl pemitiea ota rin.up a�S1.S00.Of1�nJ/or one•year imprixonmcnt,iy wc(I Js civii penaltias in�he form of a STUP WORK ORDER and a fi� •�f up m 5250.00 a Jay a�uia�l tl�e vi�laior. Ije advi�cd thut a cupy uf�his�iatcuunt muy br turwuduJ to iho UI)ice�f Im'.,ng+uu�u ol'ihe DIA for iiisurar.ce :ooen�c verifica�iun. /Ju hen•b�r.ni/'y uu.ler t/�r paiar m�d penu/tkr u rJNry�hw Nrr in�ormnlloaOrovidev ubow i:uw�ai�J rorrect tii�t:r.�n�rt• - - , D� r � � ^ Q �•• " ? �1 - - ? � O/JJria!�rt ux/yt Oo ent wrlit/a ibb arra.Iu be ruwip/r/ed by dIy oi/oww ofj)rluL Cilyor 'I'own: __. YermidlJeenseK hwlnK :�Whuri�y (circk one): --- - . ' !. 1lu�rJ uf Ilerith 2. ISuildin� Oeprrhnent ].Cit�lfoNn Clcrk a. Electrital Inspaetor 5. Plmnbing lnspcctor G.O�hrr C„uWet Pcrsou: _ I'honc p• Information and Instructions � , �ty+sachuaetu Gcneral Laws chapta l32 nquites all employ c�wuroe�e�Ke f anoiha unlu any�conaacte of dire. Purwant to�his s�atuce.an ewpleY�t it defined as'...evaY P� e�press ur implicd.unl oc wric�ea" >n�r�plo�w is deti°cd as"�s individud.p+�onanh�P. utocia4o�,oorpa�p°°ar od�I�al a�ty.or any twro a mae p� ot�he foa6���t�^6altod in a joint nuerpriaa,aod ioclwtiry{the lepl repceaencuiva ot a dece:�+ed ertPloyer,or uwcia�ion or orha leQal eautY.ta�pbYu+i t��Y� Nowevcr cde C [CCdVC►�ItW�Of�1 Y1d1Yl�li��� �WAO t'dlAO�(�!lC10.Q lbQ OOC�O�l� OWIIC[O�i QM�C����b1V1�j GO�III01'C fdY�C� �welli���o[�O°����1On����m����•c��Q�«repnir work oo such JwaAia�houaa ur on�he gro�adt or buildine appumn� tsereoo s6a11 aa bepuse o[weA eayibym�be deemed�u bs ra empbya.• �iGL clupter 152.423C(6)a1w smas�hat"wery saN w beal ltee�sht�C��Y��witYYeW tN isswaee or m o raN�lusiwt or b eo�slruct bui�dleia 1�td�eommo�we�W[er ur re�cwd sf�Ikew or���aW�evidaae�ol coopW�ce wW tYe Insura�a covsn��required." ���t wM lua�at Prod AJditwnaUy.MGL ehap�er 153.$25C('71 uaoes"Naidrcr t6e comm�wealeh uor mY of in poli�ieal wbdivisioos�hall ���aoy contiaa fa elte perfornw�°'�W'��wotk until uceptable evideace uf comptianea widi t6e inwnnee rcquiromma ot ihit chapcar haw been presented[o d�e conaaeani audwriq." :�pplk�ot� Ptease fill out ehe aorkers' eompeosacon at73davit rnmpkoely.OY checkcm�che boxa�hat apply w yaur siWarion an4 if neea+cary.smPV►Y�b�e°��(s)°�(s)•�ddce+�les)wd Phoae awnbec(s)aloaa with d�eir certificate(s)of insivanee. Limirat Liability Companies(LL�or Limited Liability Pammnhipt(LLP)witb oo tmploYoa otMer�haa the memben or paMers.�re na re�1W rad�°�s�'w°���°O�1On���' It an LLC or LLP doas have employees.a policy is roquited Be advissed ehat�hu stTidsvit may be s�bmicted w the DeP�amrnt of Indusaial Accidents for conHrmation of ineuran�e�°vtt�a A1w W�ure to ai`n and date the vflldavi4 The ut'tSdavit should be recumed w Ju ciey or rown�ha�[6e applica�ion for tlu permit a I'uenx is beine requested, not�he Daparmncat of ln�u�caiul As.:i�enu. S6ould you havn m+y q�°�Kia�g��°w or if you are raquired co obtain n worken' compawuon po1uY.P��l���st che numbar liated below. SeIP-insuced companies sdould eaur the'v .nlP-insurance licenae number on the l�. Ctry or Tow�Oflklab � . �.,..-- Plcax M:wce eha[[he a�davit ia complrte and pnnted lcgibly: T6e Department has provided n spuce su thC botwm. ot ehe affi�vi[for you m fill out in che eveat du Offiea of Investi�.uions haa w contact you reQardinQ the�PD���� 1'I�axr be sure co till ia tAe p�:tmitllicense nutnber which will be u+ed aa a rcference nwuber. (n adJidon.:u�applicant �hrt muct submit muttiple permitllicense applicarions in any given yeaz,need only submit onc a�duvic indica�ing cucreat policy informacion l i[nncessary)and under"lob Sia Addrcs�"�he+pplic�n�should write"•rll loc:a�ionr in (ciry ur �uwn►."A aopY of�la u�id�vit�lut lut boen otTicially srompeJ or muked by�he oity or town may be providcd w ehe spplicant as prouf�hat a valiJ affidavit is on fila for futurc pertniu or licensas. A naw affidavit must lx tilled out eaeh yeaz. Where a hortu uwner or citi7cn is ob�ainia�a licenve or pmnit mt related�o;�ay busiaeu or commercial venture '�'"'"' �i.e:•r du�{liemae a�ermi�w b�►luves etcJ aaid pasun_ir,YOT required co complete this at'fiduvit�Y _ �_ 1'hc Oi ii.e of[avastig�duna wvuld Iike to th�nk you in�Jvance for your�ooperaei�n anJ shoulJ yuu hava:u�Y ques�ieas. pkaaa du not hesica[e co givc us a csll. 7'ho pepanmrnt'�addtess.eelephone and fsx number: The Commonwesltb of Massachusetts pepactment of In�ustrial Accidents OA[ee ot[�wstlpdo�t 600 Washiu�wn Street goston.MA 021 l 1 Tel. p 617-72'1-d900 ext 406 or I-877-MASSAFE Fau M 617-727-7749 z���.�d >-��-os www.masa.gov/dia Cr�r og S� - - - - - PUBLIG PROPRER'TY - - - DF.PAxTUENT �.V:r\lat'�WA4L a���.s t�C�.��::�:iatsr�iu:+�.X.v►wu�a��s::a. 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