10 WHITE ST - BUILDING INSPECTION (14) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Slrrnl'RLEY UMLSCULL
M.%Yoa 12(:wesnaxc'roNsTRwr 4 sAlEw.WAssActn.,*rlxo►97.`
ThL 9M745.9595 •FAx:9771-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
Applicant Information Q ^7 Please Print Leeibly
Name tauvociat/Organintion/ /l/lndividual): i G, A"'-fa ( �)1 r �[cC
.Address:
City/Stare/zip: / Q_ Phone!/: S
Are y an employer?Check the appropriate box: 'type of project(required):
1.E2 1 um a employer with 4. ❑ 1 am a general contractor and l 6. ❑ New construction
enploycrs(full imd/or part-tine).• have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
h ship and have no cmploywa Them.sub-contractors have 8. Q-Demolition
working for me in any capacity. workers' comp.insurance.(no workers'comp. insurance 5. ❑ We are a corporation and its 9, ❑ Budding addition
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL l LC] Plumbing repairs or additions
myself.(No workers comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees: (No workers' 13.Q Other ��7 t
comp. inwrans a required.]
•A.ry upplicaut thin checks boa 01 must a6a till"the seelioo below Slowing Chair workers'cumyaaudiun policy in6antutitm,
'I twnwtwnrn who submit this anidwit indicating shay ors Joins as work and than hoc outside eonrrailora moat aubrnit a naw amdavit indiaiing urck.
:Canrracwn thol chock this box mud anad od an additional Jot.bowing the natao of dte mb-contracmn aad iheir workers'amp•pisfay fi inrarmatim.
I um an mnployer that Is providing workers'compensaden insurance for my employers. Below Is rho pulley and job.rite
hlfUfMUr%!I/L � (
Insurance Company Name:14,)6ofe .f,, _�e-{62
Policy 4 or Self-ins. Lic.0: __. . Expiration Date:
Job Site.Address: 10 l./h / s -�ti Cityislate/zip: 0/27 0
Attach a copy of the workers'compensation policy doclaralioa page(showing the policy number and expiration date).
Failure to wcurc coverage as required under Section 25A of.\,IGL 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 5250.00 a day asuinsl the violator. lie advised that a copy urthis statement may be torwarded to the Office of
Im cangatiuku of the DIA for insurance sewerage verification.
I do hereby certify under Ilse pains acid shies of perJnry that rho information provided above is true and correct.
Si•a:unre' __ / /r Dater
Phr.rc
o/Jtrioi ase only. no not write in this area,to be cosspleled by city of town o/j/ciaL
City or'rown: Permidl.icense M
Issuing Authority (circle oitc): --
1. Iloard of Ilealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _
Coulacl Person: _ Phone p:
i
Information and Instructions
r,lassachusens General Laws chapter 152 requires all employers to provide workers' compensation for their employem
pursuant to this statute,an employee is defuud 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.Parutasb*association corporation or other legal entity,"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 trweux of an individual.prnnership.,association or other legal cntitY,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of th*
dwelling have 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 152,425C(6)also states thug"avert'state or local licensing agency shag withhold the issuance or
renewal of a fleeter*or permit to operab a business or to construct buildings in the commonwealth for any
applicant wbe boa not produced acceptable evident*of compgssm 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 fat 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.comracror(s)risings).adr m*cs)and phone number(is)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 affidavit. The affidavit should
be returned 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 am 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 lice.
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 full out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to till in ilia permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 now 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
1'hc Otiix of Lnvestiyations would like to thank you in advance for your cooperation and should you have any questions,
Meuse do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®es of Investtptlens
600 Washington Street
Boston, MA 02111
Tel. 0 617-727-4900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
Revised 5-26-05 WWW.mus.gov/dia
° IMPORTANT DOCUMENT
5 Certifiea a of Fl�j�"� Res' �` ��(,,Q s
5 REGISTRATION ISSUED BY lsl� 5
5 APPLICATIONe
Date of Shipment 5
5 NUMBERXV CNORe 03/21/05
5INWSTHIES MC.5 EVANSVILLE, INDIANA 47725 Tent Identification 5
5 rtzt.a MANUFACTURERS OF THE FINISHED 04033875 5
TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated S
5 (or are inherently noninflammable) and were supplied to: 5
S692825 5
5 RICE RENTAL CENTER S
5 115 ABOT STREET NTER#14978 4 5
5 BEVERLY MA 019155108 5
5 S
5 ;
5 5 5
Certification is hereby made that: S
5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5
chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
Serial # 8105660(6) C
5 Description of item certified:
CC57
5 WALL 6'10 X 20'W2 CATHEDRAL C
5 WINDOWS WHITE VINYL 5
5 5 Flame Retardant Process Used Will Not Be Removed By 5
Washing And Is Effective For The Life Of The Fabric 5
5 5 JOHN BOYLE STATESVILLE NC 5�
SPECIAL EVENM DIVL41011•ANCHOR INDUSTRIES INC.
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IMPORTANT DOCUMENT
5 CCrtif irate Of F1a�"]Q 5
5 REGISTRATION ISSUED BY�(� ��ls��` ` — — 5
5 APPLICATION Date of Shipment S
5 NUMBER ss 03/21/05 5
5 S EVANSVILLE, INDIANA 47725 Tent Identification 5
F121.4 MANUFACTURERS OF THE FINISHED 04033875 5
TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 5 (or are Inherently noninflammable) and were supplied to: 5
692825 5
RICE RENTAL CENTER
S5 TAYLOR RENTAL CENTER#14978-4 5
115 CABOT STREET 5
5 BEVERLY MA 019155108 5
5 5
5
5 5 i
SCertification is hereby made that: 5
S 5
The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California
55 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
121 Serial M 8105660(6) 5
55 S
�7 Description of item certified:
5 WALL 610 X 20'W/2 CATHEDRAL 5
5 WINDOWS WHITE VINYL 5
5 5 Flame Retardant Process Used Will Not Be Removed By 5
Washing And Is Effective For The Life Of The Fabric S
5 JOHN BOYLE STATESVILI E NC ) 5
5 Signed: WtUEAL EVENTS 5
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5
5
5 CUtififate Of 'late ArwItan 5
REGISTERED V
ISSUED BY �e 5 APPLICATION R
5 rj NUMBER s Date of 3 9accture 5
INWSTRIES ING 5
F121.4 17 EVANSVILLE, INDIANA 47711
Order Number 5
5 MANUFACTURERS OF THE FINISHED 183949
5 TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to:
5 RICE RENTAL CENTER 5
5 DBA/ GRAND RENTAL STATION 5
5 115 CABOT STREET 5
5 BEVERLY MA 5
01915 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant a 5
5 chemical and that the application of said chemical was done in conformance with Calif approved
Fire
5
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial #:
5 8043300 (0001) 5
CSJ. Description of item certified: 5
5 FI PLS MID 40W X 20 VL W W 5
5 5 5
Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric C5
5 Signed: � k ���Name of Applicator of Flame Resistant Finish C
rJ�rJ�rJcPrJ�rJ�cP�PrlcPrlcf�frJ�rJ�rJ�tPrJ�rJcPrlrl�ePrlePcP�MPcPcfcPcP�PrPr1�f�PrJr??fcPrJ��PrJrJ�rJ�r?PrJ�cfcPTENT DEPARTMENT—ANCHOR INDUSTRIES INC.
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REGISTERED 7 ISSUED By
APPLICATION : ANCHOR INDUSTRIES INC. ufacture
NUMBER Date of Man
EVANSVILLE.INDIANA 47711 3/13/97
4
F12 4 MANUFACTURERS OF THE FINISHED Order Number
TENT PRODUCTS DESCRIBED HEREIN
1
This is to certify that the materials described have been flame-retardant treated
(or are inherently noninflammable) and were supplied to:
RICE RENTAL CENTER, INC.
115 CABOT STREET
i
BEVERLyi MA
01915
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant
approved chemical and that the application of said chemical was done in conformance
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 1o9
The method of the FR chemical application is:
Sepal a
8043800
Description of item certified: (0001)
ttm FI PLS END 40W X 20 HO VL W W
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Name of Applicator of Flame Resista nt inish F Signed: /C
TENT '+RTIVIENT ANCHOR INDUSTR-----iES INC .
I
Tierttftrate
�f IUlne 'It'st,stttl1CP
REGISTERED is
ISSUED BV
APPLICATION ANCHOR INDUSTRIES INC. Date of Ma^ulaclure
NUMBER EVANSVILLE.INDIANA 47711 3/13/97
F121 4 MANUFACTURERS OF THE FINISHED O tler Number
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have beer! flame-retardant treated
(or are inherently noninflammable) and were supplied to:
RICE RENTAL CENTER, INC.
115 CABOT STREET
BEVERLY MA 01915
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant
approved chemical and that the application of said chemical was done in conformance
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109
The method of the Fill chemical application is:
y1q Serial p:
8043900
Description of item certified: (0001),
gqp Fl PLS END 40W X 20 LO VL W W
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Sig -� 2
Name of Appli ofFl
cator ame Resistant Finish nd Itkr
%I!I
TENT ARTMENT-ANCHORINDUSTRIESINC.
!
PUBLIC PROPERTY
DEPARTI4IFNT
KuaAExcY D•IS-•u,
Nwvol 130 WAML% "S11M•SMAW YAMAOaYtTnt01970
TEL•97L74S 9S"•FAx 976.740.91N
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLMON, OR CHANGE OF USE OR OCCUPANCY FOR ANY E31ISTING3
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: ss k e 2,- N,, Building: —
--- . -
Property In located in a;Conearvatbn Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Le--40�'(c-EC—5 f- � -e
Address:
/O
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN PYISIIN3 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
8dd Description of Proposed Work: 0/ 16n7
�r-ec eK flF efD`��D �Qn`i Dre2L80c-u , �
------- Mail Permit to: ---- - ---
f
What is the current use of the Building?
Material of Building? 0 dywolling.how many units?
Win the Building Conform to law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanles Name
Address and Phone
construction Supervisors License# HIC Registration#
Estimated Cost of Projed S. Permit Fee Calculation
Permit Fee S -J •ClO Estimated Cost X$7I311000 Residentiai
-- — - -- - - Estimated Cost X$41/s1000 CammewA* -
An Additional$6.00 is added as an
AdPhinistrative charge.
Make sure that all fields are property 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 4Z240
7
,31
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