6 WHITE ST - BPA-08-395 REROOF CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Ttt:97t-745.9595 a FAX:9M740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrictans/Piumbers
AanlJcant Information Please Print Legibly
Name IauaincuANI nizatiorttindiv,duon: &C L)G/yl 9-�Zd 9n Care_ e
Addre+s:-Z22 �Pst/Lfi
city;Starcizip: 9276 phone 7V 665 3303
Are ou an employer?Check the appropriate box- Type of project(required):
1 1 am a employer with 4. ❑ 1 am a general coutrxtor and 1 6. ❑ New construction
(( employees(full andtur part-tine).• have hired the sub-cuntractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling
ship and have no employoca 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 !0. Electrical re
rcquin:d.) officers have exercised their ❑ pain or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.j t employees. [No workers' 13.❑Other
comp. insurance mqusred.]
•Any Vplicant the chccka low el mass also fill ua,the weliaa l low ahowiag their worked'cumpen"a4m puiicy iofitnrmdinn
' 1 Wmm,worra who submil Ihia affidavit indicating they am doing all work and than hire oesida a mmom moat aulmtil ,new arttdavit indicoing rick.
:Cot%irxtas the chuck this box must anacha I an x1didunai Am showing the nmoa or Ma sub.contncloa and ohm wurken'comp.policy intimmaion.
l am an employer that Is providing workers'compensadon bisuranee for aly employees. Below is the policy and job sits,
iaformmwn.
Insurance Company Name:
Policy 4 or Self-ins. Lie.0: _.. _. __.. Expiration Date:
Job Site Address: City/State/zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to seeing coverage as required under Section 25A of.\IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonincnt,as wail as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of
lovcmigaliolis oftlie DIA for insurance coverage verification.
l do hereby certify under die pains acid penalties afperjury that the information provided above is true and correct
uate•
Pht,nd,�: 7dl f�6� .33D3
OAid are only. Do nor write in rhir area,to be completed by city of town offlciaL
City or Town: _.. Permit/Llcense
Issuing Authority (circle one):
1. Board of liealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
G.Other
Cnntacl Person: — Phone p:
Information and. Instructions
Alassach"cas General Laws chapter t 52 requites all employers to provide workers' compensation for their employees.
pursuant to this su uute,an employee is defined as"..every person in the service of another under any contract of lute. '
empress or implied,oral or written."
An employer is defined as"an individual,pare mship,assod-ti u corpo cation or other legal entity.or any two or more
Of the foregoing engaged in a joint.entetprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual.perm"blup.association or other legal entity.employing employees. However the
owner of a dwelling house having not more than three apartments and who resides the er the occupant of the
dwelling house of another who employs persona to do maintenance,construction or repair work oo 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 I52.425C(6)also states that"every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the cominoawealth for any
appnoant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,425C(7)states"Neither the commonwealth a"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 number(s)along with their certificatc(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•alfidavlL The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department o
lndustriul 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
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 till in the permitflicettse number which will be used as a reference number. In addition,an applicant
that must subunit multiple permitilicense applications in any given year,need only subunit 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. Anew affidavit must be filled out each
year. When 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.
I'hc Otiicc 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
Ofilee of Investlantlotaa
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE
Fax S 617-727-7749
Revised i-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tJC W.%Q CQ7.-ON Y:sest•SAU%k%L%VLN::LL IL 41b%41:
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Construction Debris Dispossf Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition otthe State Building Code. 7110 C1611t section 111.5
Debris.and the provisions of M. GL a 40.9 S*
0uildin{Permit N _ is issued with the condition that the debris rmdtins prom
this work shall be disposed of in a property licensed waste disposal facility as defined by WL c
I l L. s 150A.
The dcbrs will be transported by:
— — inane o[hauler)
fhe debris will be disposed of in :
.LA1000( boo-AA�
(mane ofruilay)
�F /6 e
EIT�OF
PUBLIC PROPERTY
DEPARTMENT
ri..oen.aV..RISC,,.
W W! 130 WASUNGTCU SnBar•sw,.4 w,.Aaws.,,s 01970
APPLICATION FOR THE REPAIR. RENOYATiOPL CONSTR><rr_ rION.
DEbiOLTTION.OItCHANGR OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
i.o SITE INFORMATION
L=dan Name: ' Sumng:
Prop"Addreas,--
^p�_� - - --
Property is located in a;Conservation Area Y/N Historic Obtfct YIN
2.0 OWNERSHIP INFORMATION
2.i Owner b1 Land
Name: —
Acidrses. 6 oti c ,;—, S oxiLl
Telephone: 7 ST 8X .
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIIIWO 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
Bost Description of Proposed Work:
J s�
--- ------Mail Permit to: --- -
What is the crurent use of the Building? cS
Material of Building? 1,L)e9oa K dwelling.how many units? _
"the 8uitding Conform to Law? Asbestos?
AMINN WS Name
Addrea and Plwne $ '
Mschankfs Name
Addre and Phase /2c� ,l AZ-1/1 � /�
ss 2!�S 2
Consin wibn Supervisors Llesnss d H� won d
of Project-a Pon* Caleulstlon
Estlrnatsd Cod X$7/:1000 Residential
EdmatsdCostXitl/$1oo0C4mmeneia4- ------
An Additional$5.00 Is added 88 an
Administradve charge.
Make sun that all fleids am properly and legibly written to avoid delays In Processing.
The undersigned does hereby apply for a Buildup Permit to build to Ow above stated
spwAcatw& Signed under penalty of perjury
date '�5 0
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