41 CEDAR ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: BnlldawcontmctorsMectrlcLm/Pinmbers
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Applicant information Plan
se Print Legibly
Name( 'dual): de-5 tl, the B �o7V
Address:_city/state MP:— swarm /hi Phone#:_ 97,fl -
An-you m employer?Cheek the appropriate lost
1. I am a employer with—_ 4. ❑ I am a general contractor and I Ty!»of Pml«�(n9utrean:
employees(1h11 anther part-time).• have hired the wb contractor 6 ❑New eonatmctiou
2.❑ I am a$ole proprietor a partner6 listed as the attached abeet. t 7. ❑Remodeling
ship and have no employees These have S.
working for we in any capacity. wasters'comp,innuance ❑Demolition
[No wcrkem'comp.inanance S. ❑ We are a corporation and its 9 ❑Building addition
required.] ofRcas have exercised their 10.0 Mcctrical repairs or additions
3.❑ 1 am a homeowner doing an work right of exemption per MGL 11.0 Plumbing repair or addiriong
myself.[No workers'carols. c. 152.f 1(41 and we have no a Roof repairs
1081' required I t �PIaY [No workers' .13 13.EfOther ✓N V L s/�//V G
gyp•iWIMIGN required.] --a
'Any WPmw eat docks box N moat deco a0 out do ucnco babe showioa riatr wodhao . .
Hmuowom who at"this agidxvk they m dotes dl wash and 60 trite amiss 001201100 1=ON sclsak 4 am affid"
=Coeeaetms dot cbeck dds bar mmt woaehad ore addido d show A wiog the anew*too sad their wakes'eouppDOW iothemaa
f am as anployer that/a providbsa workers'coarpensatlon lasnrencpfor. Y easptoyeea Below tr tAra
Wermadon nr poky and fob Me
Insurance Company Name:— %f4l/fsr✓&.5 Policy#or Self-ins.Lis#: G_ /�U/i - Q c�H/C�J w '-cm U Expiration Data.—L22 Z 7
Job Site Address: 4G7-62 $ City/St W7!p: 5"Mt ,ry/ fi
Attach a ropy of the workers'eompeeaatlon pocky declaration a �, c5
pap(showing the policy number and aspiration date),
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of
fine uP to S 1,5W.t�0 and/or one-year imprisonment,as well as civil tmpoa criminal penalties of■
oPup to 5230.00 a der a penalties in the form of a STOP WORK ORDER and a f m
Y S�the violator. Be advised that a copy of this statement maybe forwarded to the Ot1ke of
Investigations of the DIA for hwwA co coverage verification.
f do hereby cerdP under the pabst and pena/des ojperimay that tha in/ornradan provided above is&w and correm
Phone#: 92e-- 97e -
odlew use on6% Do not write G th6 arrq to be completed by city of tows oJ)leld
City or Tows: Permit/Llcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Clty/towa Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person
Phone*
�l
Information and Instructions
%lassach_ ter i 52 requires all employees to provider workers- compensation for their employes.
us General Laws chap as ...every person is the service et another under any contract of hit%
pursuant to this smtuoe.an emP1008 is defined
pursuant w
express at implied.oral at written.
" association.won or other legal entity,or any two a more
individual.partnership, to or the
An enr Oyer is defined as"an of a decried employer.
of the ongoing engaged in avioint entesyriak and p�P+ �l�`the legal representativesof a I employees. However the
_ association at other legal entity.emP
receiver at
owner of a dwelling house having not mare than three and who resides thaein.at the ooc+tpant house
house of another who employs Petsoas to do maintenance.coosoctuction or repair wodt on such dwelling
at on the grounds at building appusteu>►m
thereto shag not because of such employment be deemed to be an employs."
agency shag withhold the issnanee Or
Mr chapter 152.12=6)also states that"every state or legal licensing
a business Of to enasb alit buildings is the gommeawealtY for aqr
renewal of•tleesss or permit to as Operate �� �of eomptlaue with ty Inaursea coverage rM>�-
applicant who has°�produced smms"Neither the commonwealth nor any of is political subdivisions shall
Additionally.MGL chaplet 15pet ft nce of public work until acceptable evidence of compliance with din insurance
�� for
WWI tscontract
� � presented m the contracting authority"
Applicants
please fill out the wodLeW comPensanon affidavit completely,by cheekins the boxes that apply teyoui situation"if
y�.conaactor(a)nsma(a).address(es)and phone number(s)along with their cati6eam(a)of
necessary.supply ability companies(LLQ or Limited Liability partnerships f LLP)with no employees other than the
instrancs• Limited an not required carry msuranoe. if an LLC at LLP does have
Or to workers'compms y be
members p� t� Be advised that this affidavit may submitted to the Department of Industrial
emplaYr a Polley of insurance covenga Abe be son to sign and dam the afndavtL The affidavit ahotild
Accidents for confimation of
be returned to the ciery or town that the application fat the permit at license is being requested.not�0
Industrial Accidents. Should You have any questions regarding the]taw at if you are required to obtain a workers'
call the Depasmt�at
the
h number listed below. Self-insured companies
compensation policy,please should eater their
self-inaresee license number on the
City or Tows Melilla
lees and printed legibly. The Department has provided a space at the bottom
Please be
sure that the affidavit is comp ffice of _ to contact You
of the affidavit for you to fill out�t event Owhich will be used as a�ference number. addition.an applies
please be sum m fill in the Ie 9
it applications in any given year,need only submit one affidavit indicating current
that must submit multiple Permrtllice°s°app the applicant should write"all locations in_—(crty at
policy information(if necessary)and under"Job Site Addeeas" the city or town may be provided m the
of the affidavit that has been officially stamped or marked by tYeach
town)."A copy s on file for Rum permits at licenses A now afLLdrvir must m filled out venture
applicant as proof that a valid affidavit' a lfcem at Pit no related to any or at commercial venture
year.Where a home owner t citizen is obtaining to complete this affidaviL
(i.e. a dog license at permit to bum laves ern.)said person is NOT required
like to thank you in advance for your cooperation and should you have any questions.
The Office of Tnvestigodo ns
please do not hesitate to give wus a ould like
The Depactnent's addres4 telephone and fax number.
JU Comm onweath of Massachusetts
Deputnc t of Industrial A=&nts
Offl a eat IavatlPttona
600 washingtOn street
Bostonb MA 02111
Tel. #617-727-4900 Cd 406 or 1-877-MA&WE
Fax 0 617-727-7749
Revised 5-26.05 www•IneS pv/dia
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CrrY OF SALE&
PUBLIC PILOPEM
DEPAWMENT
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The debris will be disposed of In:
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EITY-OF S L --
PUBLIC PROPERTY
DEPARTNIEINT
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NrAYD{ 130 WASHINGrnN S-MEEr "LEW MA.titnoil:Stl15 01970
14L•97e-745-959S•FAX:97&740-96"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
!.0 SITE INFORMATION
Location Name: Building:
Property is located in a:Conservation Area Y/N Historic 0h&Ict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner ofLand 00/vno
Name: e- u Ai1)A -r,,(j5
Address: 5"7—
_5 4-7, f1 I)V
Telephone: 99$-- 7 — G 7
3.0 COMPLETE THIS SECTION FOR WORK IN BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolidon Existing
Approximate year of Area per floor (an Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: 6 4#n5�
iv n
What is the current use of the Building? C �I b
Material of Building? tO 116 9 If dwelling.how many units?
Will the Building Conform to Law?
Asbestos? Px` d
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone q/
Construction Supervisors License# 0 SAG 35 HIC Registration#
Estimated Cost of Project$- 0 4 Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000CommemW—
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the/above ssttateed,
specifications. Signed under penally of perjury X /
Date (d
yy
w� n
a o
E• '� � 'aa G7 � L $
4