11 CHURCH ST - BUILDING INSPECTION 501 (002) •
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M,►YM
tM w SUM 4 ULEK marts oI970
Tat.;W&743-"" o PAM V8,740At46
Workers' Compensation Insurance AtHdavit>: gyuderWContraetor$Moth{etanW?hM
Appilcaut Informationben
Name
Address:
City/Stat&MP: Phone
Are you as emPloyert Check the appropriate bon
1.❑ I am a employer with 4. ❑ I am a Swag mot and I �1M e[proJeet( :
employees(firil totdlor part-time).* have hired the subcontcacun 6. (]New construction
2. I am a soli proprietor at parmec6 listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subeontrectors have Demolition
working for me m MY capacity. workers'Comp insurance.
[No workers'comp.insurance s. 0 we am a corporation and its 9 ®Building addhim
required.] o86eers have exercised their 10.0 Electrical repairs or adMom
3.❑ I am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additions
myself.[No workers'comp, C. 152. 41(4),sod we have no 12.0 Root insurance required.]t employees,[No workers' 13.0 Other 6 0/` .
comp.imm�apee required.)
OAny WHOIm tier dmdm box at matt Ww ter o s the section bdow d onlsa drir wet..'oompmmdea yeaal
ttaxrowbo wbo whir dtk aMdavk mdtntly day w dabs as wok d dba bkb exexide eaaaaaon mop.nbmk•hew atad.vk
re s s.omn xba e6eelt err tea mitt axmebed m additlod rhea xbowma do rum.of dw erb•eanoseoas and A*werlon•Comp mfinesdo wacaft�a
lesson employer that 4 provldbq workers'eompenaados lnsoresei or
In/ormotlom, I �'rnrployta Below V+ke poBry and feb rAAr
Insurance Company Name:
Policy N or Belt-ins.Lie.N:
Expiration Date:
Job Site Address City/State2ip:
Attack a copy of the workers'compensation policy doctored page(she the
Failure to secure coven as (showing Po8e7 somber sad expiration
date}
ge required under Section 23A of MGL c. 152 can lead to the imposition otcriminal penalties of a
fine up to 50.00a d and/or one-year imprisonment,as we 11 as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S2s0.00 a day against the violuer. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
�,f do/ureby erri/ pe4ra psna/Nea 01,T
/ r/ory that trite!n/oiawdon provldrd above!s trw and eor►ed
0
Phone N
OJJlclol oar only Do not write In this arty to be completed by clfy of tows offlew
City or Town. PermlilLiceose N
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City rows Clerk 4. Electrical Inspector S. Plumbing inspector
6.Other
Contact Person: Phone N•
Information and Instructions .a
tat 152 requires all employers to provide workers' compensation for their employees
%la"Whusetia Geoeral Laws chap u defined "...a,rery pew in the service of another under any co°sad of bite;
pursuant to this striate.an swpfoJree
express or imp"oral of wrine6"
as"as iadividual.partnership,sssoctatics. 0n er°�legal eased or any two a eras
An esrpfoye+is defiled ves o[•dece,ample empens However
r t
and iachtdi»<>be b:gr1�� ens, However the
of the foregoing engsied a s joint mmrpnee. atsoeiatW&er other lcpl costa.cmP*W employ
receiver or trews of an individual.partnerships who resides therein.er the ooeul s a of the
owner of a dwelling house having not eras than three apartments d scum or�wade as sueb dwellin{home
dwellius hone°of ascthsr who empbYs msh�ill 0(such employers be to be an emPbyer'
or on the grounds at building ePP�e ssea thareft ar wed ftessing seamy_
Withhold as MGL chapter 152.12SC(6)also grata°thsa � eestteset bslWlsp Is<w eemmesweattr�MW
resesal of a saw"of or perm to°panes am@ Hamm wW the issnrasee eoverap regdre'L"
ptable evi Of cOmP Ay of its Poll"
apA ti t.MGl.aspecbe to sat 152.produced� Ne acceptable evidt a o[eemplianee wits dw�fu"
enter of6ischapter�ct for the��e of public worit p�ted to the eoatsactini wry"
rcq
Applicants . affidavit completely,by cheelnng the boxes that apply to your situation aud,it
of t
Please fill out dw necesaary.aup*a'b'c°naseter(� a)name(s), L abOO�number(s)along with their Patmershipa(LLp)wob no�s)other than the
inavnae. Limited Liability Cb mtpmm(LLL7 at Limited Liability
insurance. If an LLC of LLP does have
atembers Of patman.as not required cn dvised that this&M&vit nay be submitted to the Department,h affidavit a��
•policy is to insurance coverage. Also be sure to sign and data the afgdavlL
confirmation a goon for the permit or license ' sot the Department of
bbee r cidents cmmWm era town that the application the law a if you a n required to obtain a workers'
industrial Accidents. Should you have any questions regarding
compensation policy.pica"call the Dept 01 the member listed below. Sal�iuwted companiessbotild camself-inwraues license�sber on
City or TWO Officials has proves a space at the bottom
Please be slue that the affidavit is complete and printed legible. The Department you re der the applicari.
of the affidavit for You to fill out is the event the Office of Investigations has to nomad y gar i
Please be sure to fill in the permivUcnse number which will be used as a reference number. in addition,i an applicant current
lications in any gives year,need only submit one affidavit indicating currant
that must submit multiple permidlicense ePP Job Site Address"the applicant should wrier"all locations in----(c*or
policy information(i[necessary)and tinder or madred by the city or town may be provided to the
town)."A copy of the affidavit_that has been officially stamped ermits or licenses. A new a("-&vu must be filled cut each
applicant as proof that a valid affidavitts 06 a license or Permit nor related to any business or commercial vsntiue
year.Where a home owner a citizenu NOT required to complete this affidavit
(i.e. a dog license or permit to buts leaves ate.)said person
The Office of investigations would like to thwk You in advance for your cooperation and should you have any questions.
please do not besitam to give us a eaU
The DepuuMeoe's address,telephone aIU v/Wth dUWtft
Department of lnfilmfal AM&Mts
WIN of vvadpdons
600 wash] 9M sorest
Boston.MA 02111
Tel. #617-727-4900 W 406 or 1-877-MASSAFE
Fax#617-n7-7749
Revised 5-2"S wwtr MMLgov/&a
4.
CITY-OF�XLE;� ---
PUBLIC PROPERTY
PARTMEINT
NAroa IDS - 0 --3 130 WASMINc.Zi7N 5W=0
sum MAsucrosLrM 01970
74L 9711.715-9S"•FAX 978-740480
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCL��ivey FOR ANY EXISTING
STRUCTCRIC OR BUH.DT 1 O%
1.0 SITE INFORMATION
Location Name: Q t3uilding;
_. ._ PropM -
Prop"is located in a:Conserva0on Arse YIN Historic DWbkt YM
2.0 OWNERSHIP INFORMATION
2.1 Owner cii Land
Name: _
Address:
Telephone: %7 - — Ooo.
3.0 COMPLETE THIS SECTION FOR WORK IN MaSMh[Q 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
Bdet Description of Proposed Wo q
�r? cr' '/S l�l Q�O b Yp' 0rc, (Q
.
-- - Mail Permit to: r.` c/Q
What is the current use of he Bul ing?
Material of Building? If dwelling.how many n to Law? Asbestos?
units?---
Coform �O_�_
WiM the Building
Architect's Name
Address and Phone
Mechanic's Name S
Address and Phone Constriction Supe HIC Registratbn 5
rvisors License 5
Estimated Cost of Project i / 0 Pam*
D Estimated Cost X i7/i1000 Residential
Perrm�Fee i-25
- Estimated cost i11/i100O Comrmeroia4--
-- - - An Additlonsl $5.00 is added as an
�~ Admini'stri charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building P bulld to a slat
specftatkms. Signed under penalty of perjury
Date
L o
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All
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