63B WHARF ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTM- ENT
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Construedoo Debris Disposal Affidavit
(required for all demolition wA removados work)
in=onWm with the sixth edition of dw State Building Cody.730 OUR section 111.5
Debris,sad the provisions of N(GL c 40.S Sk
Building Permit A _ . _ is issued with this condidos that the debris resulting hoes
this walk shall be disposed of in a property licensed wage disposal fbeitity as dented by%1GL c
t 11.S 11OA.
The debris will be transported by:
i\:JMpS�-
-- In■t+e�or hsulmal
rho dcbds will be disposed ofin :
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
hH1{4`'R{F.Y URIYarl
M%ytat 12C WASHM-.11CINSUM a SAILIEK l<�stc tn.a i tsOt97�
Tut.:M745.95" 4 Fax:9M74C.U46
Workers' Compensation Insurance Alldavit: Builders/Contractors/ElectricfaiWPIumbers
applicant Information l Please Print Legibly
Name inusint /ratlaNlmbV ultotl)C J 11�t C1 1 I_G.
•:+roman I
AJdrC+s Le) 1�ca.rpr,.Hh s'1
City/StamJZip: Sc � IL /M/E 0i-1 (o t) Phone ll:
Are you an employer'Cheek the appropriate boot:
1.Q 1 am a employer with 4. ❑ 1 am a Sensual cootraetor and 1 pe of project red).
6. Q New cortatrechottetion
ernptuyt.•as(full arroUor pan-time).• have hired the aub.eumractoa
2.Q 1 am a sole proprietor or partner- listed on the attached sleet ❑ Remodeling
ship and have no ampksyeas These wbconrcactors have g Q Demolition
working for ma in any capacity. workers'comp insurance. q. Q gygdigg addition
INo workers'comp. insurance S. Q We are a corporation and its !0.Q Eltxtrieal repairs or additions
requin:dl of ioers have exercised their
3.Q I am a homeowner doing all work riglu of exemption per MGL 11.0 Plumbing repairs or additions
myselL[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof tepairs
insurance required.) t employees. [No worked' 13.❑Other
comp insurancx rcquiraxLj
nny y pf saW dims elaxba boa rl am abo rail am am actual iwbw alawiag ime ewlrkm'ewmpeetmsiw poicy im6n ssajoa
'Iluawuwrra woo•ubmin Nis omNvh ildkaling dory an Jaime tli work sad tbaa hire aande eamrocpn nasal•wana a now a1Rda•il indicting alxb.
�C.wlirsOun Cho Clod;due boa mums anal:hed as addidamml Am.bowing the name of she sobcoominent sad their wmkere'camp.policy mfiarf atiw.
I um an employer that is providing workers'compenraden buarance for my employees Below is the polity and/ob sloe
infermarlams,
Insurance Company Name: _
Policy 0 or Salr--ins.Lie.q: _ .. ._. Expiration Date:
Job Site Address: 1, 3 13 ld4AL 5'r Sc le r, CityislatuZip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to xxure coverage as required under Section 23A of.1GL c. 152 can lead to the imposition of criminal penalties of a
ri ne up ut S 1.500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day a •iost the violator. lie advised that a t y Ka copy of this statement may he Curwardad to the O/lice of
LI\Y�II'�'alp)Ila u1 tho DIA for insurance caweragu verification.
/du hereby Certify under the pains and penu/r&s of perfnry that the in/ermWlon provided above is rare and correct
tii�aature: _ . _ Date•
O/ficie/are oalyt /b cot wdit/it Als area,to br eampletml by city or town o/Jlelai
City or'rown: Permit/Lleense M __ _
ksuing Authurity (circle me):
1. Board of health 2. Building Department 3.City/town Clerk a. Electrical Inspector 5. Plumbing Inspector
6.Other
contact Pcrsats Phone N•
Information and Instructions . . .
Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their Cmpbyeaea
Pursuant to this stag an empbyee is defined as-...every person in the service of another under any contact of hies.
eapress or implied,oral or written."
An em yApyer is deffaed as"are individuaL partnership.ataoetatto&oospatation Or otter legal catity,of any two at more
Of the foregoing etrusteengaged in a joint emerpriss,and including the legal representatives of a deceased employer.or the
associative of other legal entity,employing employed. However the
receiver a dwelling
of o se having
et rW abu a and who resides tbtaein or the owspam of the
owner of a dwelling house having not more than three apormteols
do maintenance.crostruction or repair work on such dwelling house
dwelling house of another who employs Person te
or on the grounds or building appurtenant therm shall not because of such employment be deemed to be an employer.'
AtGL chapter 152. §23C(6)also stave that"every state or local licensing ageacY sit"withheld the issuane t or
renewal of a accase or permit to operate a business or to eoastruet buildings Is the commoswealtb far any
apparent wba bag aot produced acceptable evideacs of cosepoaaee with the insurance coverage requtred.-
Additiomlly,MGL chapter 152.§25CM states"Neither the commonwealth out any of its political mb"sives shall
enter into any contract for the perfomumce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contacting authority.-
Applicants
Please fill out the workers'compensation affidavit completely,by checking the bastes that apply to your situation and.if
necessary.supply sub.coneactor(s)narnc(s),address(es)and phone munber(s)aloag with their ccnifica*s)of
insurance. Limited Liability Companies(LLG7 or Limited Liability partnerships(LLP)with no employees other than the
members or partners.are not required to carry workers'compensad a insurmtee. If au LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affldavit The affidavit should
be retuned 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
,elf 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 till in the permittlicemue number which will be used w%a reference number. In addition,an applicant
that must submit multiple permivlicense 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
yew. 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 burn leaves etc.)said person is NOT required to complete this affidavit.
1'hc Otiiec of Invcsti-Sations would like to thank you in advance for your cooperation and should you have any questions,
picric du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Depament of Indusa'ial Accidents
011la of[avestlpHoaa
600 Washiogma Sited
Boston, MA 02111
Tel. H 617-7274900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 www.mLw.gov/dia
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PUBLIC PROPERTY
DEPARTMENT
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DEKOLI'it'I[OM OR CRANGR OE iI31c n>Q [YY7rt••QM a..s . ... ea
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1.0 SITE INFORMATION
Laeatlon Nama 7 !Lic r,n SWk*W
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�� i3 lffYh9 Si scdev+. Ala olerlo
Property io bcdod In a;cwwwvallon Ame YJN Hillorte t)is"m YIN
2.0 OWNERS%V INFORMATION
2.1 Owner o1 Land
Name:
Address;
Tekphorw.
3.0 COMPLETE THIS SECTION FOR WORK IN EXW MNG 13UILDINGS ONLY
Addition Existing
Renovatleon - Number of Stories Renovated
Change in Use Now
DemoUdon
Approximate year of Area per flow NO Renovated
Construction or renovation
of existing building New
adaf Description of Proposed Work:
--- ------Mail Permit to: - - -
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WS to MAMV Cow 10 Lava? c� /ybestos9
AmhRods Name
L4*d W$Name e � lfi.9`ti
Addr�and Ph" CS d 9�SL HtC RepistraUon�
CaraWuc m SUPWv'Ms Llcsnse
! C 0 U u Penn*Fa.Caleulslbn
Estlrnatsd CasR Esffinatsd Cost X$71SIO 0 Rmidsn"
Puma Fos$ Estlmdb Cost X N/f:10o6 Camnarda4---- -
_-.. An Addowid woo Is added se an
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Make a"that al flake are Wopw ,and Isgft wriaan to avow"ap In Pin¢
The undersigned does hereby apply for a BuUd ft Permit to bu above stated
spwaat ors signed under Penatty of Ps*lfy w5V-C
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