17 COTTAGE ST - BUILDING PERMIT APP CITY OF SALEM
' PUBLIC PROPRERTY
DEPARTMENT
XIMR`RUY DkI1(An1
]4.%yoR M2 WASHING IOxSTREL'T 4 SALEN,MASSACHI:.SFi-is 0197.
Tea.:978-745-9595 s FAx:978-740-984G
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
� t
Nlate(Busim,%stOrganization/Individual): L r-lsTe)op I�0r2in4
Address: t1 D`1TQCeP S 1
City;State'7ip 41J-S 1144- 01 L706 Phone #: 7 Fs-1 7o9 9 75
Are you an employer?Check the appropriate box: 'rype of project(required):
1.❑ 1 an.a employer with 4. ❑ 1 am a general contractor and 1
6. ❑ N w construction
t an
(full and/or part-time).` have hired the sub-contractors
❑/ 7. temodeling
� I am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employes 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
required.] officers have exercised their 10.❑ Electrical repairs or additions
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 anployec,. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that chucks box NI must also fill out the section ix:luw showing their workers'compensation put icy infurmution
'1lomeuwrcrs who submit this affidavit indicating they arc doing ull work arW then him outside contractors must submit anew al'rdavit indicating such.
:Comructurs that check this box must aaachW an addiliumd sheet shusving the name of the sub-eontractm and their workers'comp.policy infbnnadon.
1 arrr un employer that&providing workers'compensation insurance for my employees. Below is the policy and job site
injorinarion.
Insurance Company Name:
Policy#or Self-ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
I-ailure to secure coverage as required under Seddon 25A of:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine 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. Be advised that a copy of this statement may be forwarded to the Office of
Invcsiigatiuns ul the DIA for insurance coverage verification.
1 do her rby/i. r ify under the pa
ins and per !'•s ujperfury that the information provided above is true
and correct
Sieaalure' l �/iI /(PLL Dater �—�'U
Pht arc:i:
Official use only. Do not write in this area, to be completed by city or town officiub
City or Town: _ _. _ -..__ Permit/License# _
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. Cilylrown 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 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."
Art 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."
b1GL 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 wbo 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 rill 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
I ndustrial 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 till 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 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
townl."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 filled 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.
l'he Oil ice 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
O[flce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\IAWK 12C WA911X(T:ONSCREET •SALV%11. M.,S%C(11 iLVl]:;97C
Tf.(.:978-743-9595 •F%X:978.74C-9846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of v1GL c 40, S 54;
Building Permit # _ _ __ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by v1GL c
111. S 150A.
The debris will be transported by:
(name of hauler)
y Z. IN
�z!�-,l S�3 S.go
7'lie debris will be disposed of in
C'14A [ F � e � chA
(dame of(acifay)
. '-- addrcia of tacill Y)
ii_G.(UC: JI :C(Il'.1I 1(7(L IC1d1-- �---
CITY-OFF
r' PUBLIC PROPERTY
DEPARTMF�'�1T
130wm WAGVWs� *3nUK uANAauw„s 01970
7UL 97e.745.9"S.FNo 978-74049"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEVLOLTTION, OR CHANGE OF USZ OR OCCUPANCY. FOR ANY FMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
LacatIon Name: S euild(n¢
Property Address /-/ $0 '- U -
4A L&-NkA s5f
Property is located In s;Conservation Area Y/N Hlst Ic Dlei YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: C M =N F3jqA <, hA
Address:
y 13u)�5 VAA -5T
Telephone: C 3 3 o v 32 G S
3.0 dOMPLETE THIS SECTION FOR WORK IN EXISTIM 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
Bdd Description of Proposed Work:
-- -- ----Mail Permit to: - - - -
' � frr✓1Q✓t i
What is the current use a the Building?
Material a Buildin9T
,�/ If dwelling.how many units? -3
witl the Building conform to law? Asbestos?Architeds Name
Address and Phone )
Mechanics Name
Address and Phone 1 3 9 2
ConatnXtian Supervisors Licenses 0 7 7 9 7L HIC Registration N
Estimated Cost Of Projed i Parma Fee Calwlauor
Permit Fee i Estimated Cost X$7fi1000 Residential- Estirnatedt'.ostXitt/i1000 =— --
--
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 tothe above stated
speciftatlons. Signed under penalty a X Perjury '�� Q'
U
Date 7 Aal
of
I
4
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