281 ESSEX ST - BUILDING INSPECTION (10) A&_ CITY OF SALEM
� N PUBLIC PROPRERTY
DEPARTMENT
:Asdnr RIFY URIKs/LL
MAYOR l20 WASML2NG1'0NSTREET • SALE.N,MASSACI1451 IYs0197.
TEE.978-745-9595 9 FAX:978.740-9g46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeibly
NaMC (Bucitwss/OrganizatioNindividual):
Address:
City/StateiZip:��GG /�If} �/ll� 7 0 Phone €l: 97k
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6, ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7- ❑ Remodeling
ship and have no employees These sub-contractors have S. [/�'�emolition
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.El Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t cmpluyees. [No workers' 13.❑ Other
comp. insurance required.]
•:1ny applicant that checks box 01 most also rill aft the section below bowing Choir wurkeni compenudion policy iofurmatiun.
t 11omeownen who submit this affidavit indicating they are doing an work and then him outside contractor must suhmit a new afrdavir indicting such.
�C'untractors that chuck this box must attached an additional steel showing the nano of the sub-contractors and their wvrken'comp.policy information.
I am an employer that Iv providing workers'compensadon insurance jar noy employees. Belon,is the policy and job sire
information.
Insurance Company Name: /✓ �/�/��T�— fT
Policy 4 or self-ins. LieGit: C,�3� Expiration Date: /�60
Job Site Address: O �—�5� X f-T- CityiStateiZip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and cxpiratiun date).
Failure to wcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Fin,: up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement troy be forwarded to the Office of
Inv"n�ations ol'the DIA for insurance coverage verification.
I do hereby certify ut ti pain- ud per ' s ajperjury that the information provided above is
true and correct.
Official use only. Do not write in this area,to be contpieled by city or town ofjlciaL
City or Tern:
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 p:
1
Information and Instructions
A4assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employeef
Pursuant to this statute,an emptuyee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An etnplojvr 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."
btGL chapter 152.p25C(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. IAGL 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-contractors)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 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 he 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/licerse number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 time city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. -A'ni w affidavit must be filled our each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
l'he Off ice of lnvesrigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us u call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
O@Ice 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
.I
GRANITE STATE INSURANCE COMPANY 71007-0000 WC 235-86-o6
13102 ---------------------------------------------
013-66-o407-00
.••,-. , PENNSYLVANIA
„•IIEEiiiiiiiiii
HOLLORAN INSULATION LLC
41 F A 1 RMOUNT ST Member Companies of
SALEM, MA 01970-0000 Oil" American International Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# MA UI# "•• ••-
GERALD T MCCARTHY INSURANCE AGENCY
WORKERS COMPENSATION AND EMPLOYERS PO BOX 839
LIABILITY POLICY INFORMATION PAGE SALEM, MA 01970-0839
INSURED IS PREVIOUS POLICY NUMBER
LIMITED LIABILITY- COMPANY RENEWAL 008743627
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE" - -WC 0610
ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the Insured's
mailing address FROM 04/13/07 TO 04/13/08
ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
S. Employers Liability Insurance: Part Two of the policy applies to the work In each state listed In Item 3.A. �.
The limits of our liability under Pert Two are: Bodily Injury by Accident $ 100,000 each accident - '
Bodily Injury by Disease $ 500,000 Policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC200306A
ITEMS The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total pate Per Estimated - '"Y•
Classifications Code Number Remuneration $100 OF Re- Pnsri
191 Annual 3 Yee, munerstlon Annual-[]3 Year
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $122
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $S0O MA TOTAL ESTIMATED PREMIUM $3.208
If indicated below, Interim adjustments of Premium shell be made:
ElSemi-Annually Quarterly Monthly DEPOSIT PREMIUM
ENDORSEMENTS(FORM NUNS) SEE ATTACHED FORM SCHEDULE - WC990612
04/17/07 ASSIGNED RISK 66
Issue Date Issuing Office Authorized Reomsentitive WC 00 00 01
3999]
L
CITY OF SALEM
PUBLIC PROPRERTY
as DEPARTMENT
91 t.Y!`di]CJl1.
%1.twjt 12C W.\91IXG:0MS.REf.T •$.\Lc ft I-!
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TF.1:9 71-7 4 34 59 5 •F.-m )711-74C-;B46
Construction Debris Disposaf affidavit
(required for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions of M. GL 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 %1GL c
111. S 1.50A.
The debris will be transported by:
_ r1G Z _
(name of hauler)
1'he debris will be dispto�sed ofin
'Tvrnell- Daft
Wame of r'aciifty)
L A
i�ft�aiLty)
ClTrOF SALE;
PUBLIC PROPERTY
DEPART-NMINT
.. AIIMFN``''N- p.ItyYI
"aWAO""C;" (SiFi7 &Ua%-U&UACMS1&1'iS01970
918-74S-95"•FAX 978.740.9K
APPLICATION FOR THE REPAIR RENOVATI N CON TRUCTION
DEMRLITION, OR CHANGE O)R USE OR OCC[Jp tyC FOR ANY EXIS'PII�iG
STRUCTM OR BUILD_ I1yr
1.0 SITE INFORMATION
Location Name: g I S S r—X Js Bui
Prop"Address: - - -
2 ro/ I
Properly is located in a;Conservation Aree Y/N Historic CIebICt YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land TT Name: $ 1 I: s.5 C -,4 C J G o ��
Address s r¢ ✓h f,
Az
Telephone: 7 2 - z6'Y
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST ma 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 D/eSCription of Proposed Work:
/ ✓C�(J�SI ✓Pik'{ `� r
-- --- - -- -Mail Permit to:
S
What is the current use of the Building?
o r ( If dwelling.how many units?__
to taw? —�--
Material of BwldtrW? Asbestos?
rm .- . .
"I the Building Confo Y! s
N1S DaS n lb4� Sfc � .
Architeds Name pl4
Address and Phone 'Z 6 i�s�«
MeahanWs Name r� ^sue90 Z,
(
Address and Phone l ra wto.n fy7 09
Construction Dery license S HIC Registration 0Su
Estimated Cost Project$ /' :i 000 Permit Fee Ca wtalbn
Estimated Cost X$7IS1000 Residential
Pamnit Fee S Estimated cost X$i I/S1000 Commerciw----
-- An Additional S5.00 is added as an
Administrative charge.
Mahe sure that ail fields are property and legibly written to avoid delays in processing*
The undersigned does hereby apply for a Building
�P/e;c4 above stated
specifications, Signed under penalty of perjury X Z 0
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