10 WOODBURY CT - BUILDING INSPECTION CITY OF SALEM
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PUBLIC PROPRERTY
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DEPARTMENT
XI11111`.RILY DRISCOLL
MAYOR 12^,WMHt.1Gf'ONSTREET•SALEM,MASsnawsrrtS01919
978-745-9595 0 FAX:97 8-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name(Business/OreanizatiorJlndividual):
Address: Q �11�PT1/1 �M� / Ive
City/Stal& Ip: 0aA)VeeS l '� . 11[ltiner': I—g72r'3-7 —aa73
Are you an employer?Check the appropriate box: 'rype of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6 ❑New construction
employees(full and/orpart-time).* have hired the sub-contractors 2.Er, am 7. Remodeling a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees 'these sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required_] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ 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' 13.0 Other
comp. insurance required.]
-Any:4tphcant tho checks box it[ must also till out the section below showing their uwrken'cumpenwtion pulicy inliumaion.
'1 Jomea%ners wt.0 submit this affidavit indicating they are doing all work and then him outside cunanelors must submit a new affidavit indicating such.
4Contmctors that.heck this box mustatlachod an additional sheet showing the nauu of the sub-contmetors and their workers'comp.policy information.
l mn an employer that&providing workers'coorpenmtion insurance for try employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. —__..__ _- __-___
E1xpiration Date:
Job Site Adtlr_ss: to cl c) D&,�L Co � CitylS atdLip:li(0( l n'n'u
Attach -
a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
hailme to scc.frc coverage as required under Secliun 25A ul-MGL c. 152 can lead to the imposition of criminal penalties of a
tine LIP 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. lie advised that a copy of this statement may be forwarded to the Office of
htvcstigatiuns of the DIA for insurance coverage verification.
l do hereliy certify under d e pains nand pen ties of perjury that the information provided above is trite and correct.
Sienauu'e: •� pp L 07
Phtter 727 3 `5'aa73
Official use only. Do not write in this area,to be completed by city or town official.
City or"Town: PermittLicense#----__-- --_-. -- -.. .---_---
lssuing Authority (circle one):
1. Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5.plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniployAes.
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 otter 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."
MGL chapter 152, §25C(6)also states that"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 compliance 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 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 nuniber(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 continuation 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 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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 related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the Office 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
Office of Investigations
600 Washington Street "
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2G-05 www.mass.gov/(fia
` CITY OF SALEM
, `,'t PUBLIC PROPRERTY
<,,,� DEPARTMENT
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'rn:978-745-4595 #F.%X:978-74G9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL 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 e
111,S 1.50A.
The debris will be transported by:
(name of hauler) —
The debris will be disposed of in
(tI)ame of facility)_
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DATE OF TIE LATEST DEED OF REOORD. PACE r�0
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• 1.�SITE INFORMATION _
Location Now
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2.8 ONMERSHP INFORMATION
Ml Owner of Land
mum —
3.000MPLETt THIS SECTION FOR WORK IN
ilZma ou"MOS ONLY
Addition
Rerwvatbn stln3
Number of Stories Renovated
Change in Use:
DemolitionDemolitionNow
APWoximate year of Exig*V
Area per floor constnretlon or renovation (sf) Renovated
of sxistirq bwWtrp
New
t3Qai D@S=Pdan of Proposed Work:
Mad Permit to: — -
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