23 FRANCIS RD - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
0%fre-RIFY DN18:ULL
M. twat 1N,:WASH.%Grole STREET*SALEM.MnaACIR.'W'ts0197V
Trt:978-743.9595 9 FAX:9M740-9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AVIDlicant information J J p r Please Print Leeibly
Name(tlucincu/OrganizatioNlndividual):AN�T oAu4 7 I—Lo 9/LS
Address:_ _7 Cl ith /9-vC
City/StarciZip: Saltam 274 01770 Phone #: `�7d� 273 Q02.
\re you an employer?Check the appropriate box: 'rype of pre jLet(required):
1.0 1 ant a employer with 4. 0 1 am a general contractor and 1 6 0 New construction
ixnpluyccs(full and/or part-tine).' have hired the sub-contractors ,�,,�
2 [g I am a sole proprietor or partner- listed on the attached sheet t 7• U' +vemodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
�No workers'comp. insurance 5. 0 We are a corporation and its
requircdl] officers have exercised their
10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself, (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.(No workers' 13.0 Other
comp. insurance required.]
•Any applicant flat chucks boa nt must also fill out fhe+ection below awwiag their works t cumpentatiwr policy infurmadiaa
' f 10 %Iwtwm who submit this affidavit indicating they are doing all wont and then like outside contractor must.uhmit a new affidavit indicating much.
Cantrxtors that chock this box must anached an atdititm d.beet%bowing tho ratio of the sub-comracton and their workan'comp.policy infomtation.
fain arr employer that is providing workers'compensation insaraitce for ttry employees. Below is the policy and job site
inforvnation.
Insurance Company Name:
Policy if or SclGins. Lic. tf: ... Expiration Date:
Job Site Address: City/Slate/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,xi well us civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lic advised that a copy of this slawment may be forwarded to the 011ice of
Im esu�auons of the DIA for insurance eovcra,c verification.
l do hereby certify and a pains and prr 7rs prrjary that the htforinallon provided above!.I true and correct.
tiiL:vintrc' / > 2--y Dul
091cial are only. Do not write in this area,to be completed by city or town ofj7r4a[
City or'rown: _,. Permit/License q
Issuing Authority (circle one):
I. Board of ltealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cunlucl Person: _ _ .. _._— Phonc N:
Information and Instructions a
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee8.
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
Ar%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
not because of such employment be deemed to be an employer."
or on the grounds or building appurtenant thereto shall
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 compUance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of is political subdivisions shall
enter into any contram 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.-
Applicant
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($)'addresses)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 arc 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 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
t i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Ottix 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 s t
Department of I»dttstrial Accidents l
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mam.gov/dia
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CITY OF SALEM
PUBLIC PROPRERTY
'a DEPARTMENT
...umertr.Y! Am:01L.
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To.WW45--)M •F.%X-OWC-9644
Construction Debris Disposst Aftidavit
(required for all demolition and renovation work)
In accordance w ith the sixth,edition of the State Building Code, 780 LAIR section 111.3
Debris,and the provisions of v1GL a 40, S 54;
Building Permit J _ . _ is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by AIGL c
111. 4130A.
The debris will be transported by:
— — (named hauler)
flue debris will be disposed of in :
(name of faculty)
-� 17107 -
EI'I'Y OF
PUBLIC PROPERTY
DEPARTMENT
K1.%0 EKi f 1IR16C011
MAVOa 130 WeaaewznM bnLE¢r•sMjjK sr,-R 01970
1IL M745-M•FAZ M7404 Mti
APPLICATION FOR THR REPAIR. RENOVATION. CoNSTgUCTION,
DEMOLITIOM OR CHANGE OF USR OR OCCUPANCy, FOR ANY EXI MG
STRUCTURE OR BU LAWG.
1.0 SITE INFORMATION
Location Name: t3uildtng; S H f �,+.
---- -
23 F2AN cr-i 204 D SAlt.�q
Property is located in s;Conservadon Area YM_A( Historla tSstrlot YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: J D K It Ci?A .% 6 19D v r2 f
Address:
22 F/t rl�l ce s 20,1 ,6 le I
Telephone: `T 78 7 4 ( - /8 S
&0 COMPLETE THIS SECTION FOR WORK IN ILDINGS ONLY
Addition Existing
Renovation 1/ Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation / 70
of existing building New
&W Description of Proposed Work:
----- ---Mail Permit to: --- — -
v
What is the can e t use of the BuildingT
Material of Buiidkg? t-j o p a If dwelling,how many unmi r
wa the Building Cw tm to Law? Asbestos?
AmAdeas Name
Address and Phan
Mechanic's Name
Address and Phone
C w&uctlon Supan,isors License 96 O 4 g HIC Registration is - - -- - —
Estimated Cod Proles: 6 O Permit Fed Caleutation
PermR Fee: ` f Estimated Cost X$7/$1000 Residential
EMpnated Cost x$41/=1000 Commerclat
An Additional SS.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 stated
/,f
spw&atkxa. Signed under penalty of perJury
Date o 2
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