75 WILSON ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
iJ]Iai'RlPY 1)a11t:ULL
\.swat 12C WAM-axGMIN STREET♦SALEN,MAVACI u:sr:l*rs 01970
Tlei:978-745.9395 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anfitlicant Information Please Print Legibly
Name tBusiness/OrganizatioNlndividtw4: ,
Address: 5 t it�t=_e,/`C1� 0A\
City,'StateiZip: �� -t\ Ai,4 1A ►1 p l9U 1 Phone
Are you an employer?Check the appropriate box: 'rype of project(required):
1. 1 am a employer with� 4. [11 am a general contractor and 1
® Pto y have hired the sub-contractors 6' New construction
employees(full and/or part-time).*
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees 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
required.] officers have exercised their 10.❑ Electrical repairs 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.(a Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
cotnp. insurance required.]
.
Any applicant that chucks box 01 most also tilt out the action Wu uw showing their workm'cumponsation policy infurmatiora
' itomuowmn who submit this affidavit indicating they are doing all work and thrn him outside conuacton most submit a new affidavit indie aing such.
-C,nttracu rs that check this box most attached an additional Jteet showing the name of the subKonnactors and their workers'comp.policy information.
I an;wt employer that Is providing workers'compensation insurance for toy employees. Below is the pa/icy and job site
in/ortnutiom
Insurance Company Name: 4,e rti \�iGG�(J( _. vYC7
Policy #or Self-ins. Lic. #: Lt/C b Expiration Date:
Job Site Addres.0,3 c.J Ir�C Ot/"S City/State/Zip:.Sg
Attach a 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
Fire 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. Ile advised that a copy of this statement may be forwarded to the Office of
Inceangarians of ffic DIA for insurance coverage verification.
I do hereby certify auder lhe�ptthrs penalties of perjury that are information provided above is true and correct.
Si ,:tans Date' �/I �t�•
JO O
official use only. Do not write in this area,to be completed by city or town ofjlcia t
City or Tawn: _. - _ - Permit/Liccnse#___
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ . . _ -- _-- Phone #:
id
Information and Instructions �.
[.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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 be an employer."
IvMGL chapter 152. Q25C(6)also states thut"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 compUance with the insurance coverage required."
Additionally.MGL chapter 152,,$2SC(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of pubfic work uniil acceptable evidence of compliance with the insurance
requirements of this chapter have teen 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 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 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 arc 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 Omcials
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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 future 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 telated 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.
,,he Oflicc 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
otIIee of Investigations
600 Washington street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised i-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
'4-D
DEPARTMENT
WA9ItN'(::ONS:'REET ♦SALV%1. fit.\SiAC:LL .iLI t�:19P.
TF.t:9M745-1595 • r-A-x:97s-74G9s46
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5 '
Debris, and the provisions of vIGL c 40, S 54;
Building Permit # _ _ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111° S 150A.
The debris will be transported by:
— — (name of hauler)
i'lie debris will be disposed of in
1 csrt'c ImC..vN .. _
(name offatu Y)
I ad.;resa of CaciLt Yl .
- �__-
CrrrOFSALEX _ _
PUBLIC PROPERTY
DEPART WENT
�leroa
TEL 97LUMS93 FAX M740AiK
APPLICATION FOR THE REPAIR. RENOV ?V4F �'ONSTRUCTION
DEMOLITION, OR CHANGE OF USp ROC >pANCY FOR ANY EXISTING
STRUCTURE OR BUII;DING
1.0 SITE INFORMATION "
t.acation Narne M o. i �'C /�c,nc c/5 y� sC1c r, Building. c S
Properly Address:--75--w. SD Vv- - - Spx\,!a-vA-' -
Property is located in a.conservatlon Ares Y/N HWtorto Obbid YM
2.0 OWNERSHIP INFORMATION
X Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EY131INIG 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
add Description of Proposed Work: ( �
— - - - -- -Mail Permit to:
What is the current use of the Building? °q `�
( �,gr ri
H dwelling.how many units?_,- —
Mate W of Building? Asbestos?
WIN the Building Conform to Law?
Architeds Name ( )
Address and Phone
Mechanic's Name
Address and Phone HIC Registration 0
Construction Supervisors License 0
>7� pmit Fee Cakulatlan
Estimated Cost of project i er
Pennil Fee Estimated Cost X i7IS1000 Residential
i —
Estmatsd Cost X i11/51000 Canhmercial--- _
- - - - An Additional$5.00 is added as an
Administrable Charge.
Make sure that all fields are properly and legibly written to avoid delays In Processing-
The undersigned does hereby apply for a Building Pennkt to build to the above stated
specincetne. signed under penalty of perjury
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