7 GALLOWS HILL RD - BUILDING INSPECTION CITY OF SALEM
tt PUBLIC PROPRERTY
DEPARTMENT
:asmrau:r uatsc:utt.
M.trat 120 WARiIKGIoxS-fKEE-r • SALEH,MASSAOUSIS'I isOI97O
'rLL-978-745-9595 0 FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pfflicant Information n Please Print Leuibly
` /C..�{�L/
Name (Husitnss/OrganizatiotJlndividuut):_ �'/f/��'
Address: p //S/ 3-71- -
City/Statei'Zip: �l/��/ ,(�/� � Phone #: L `7
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).• have hired the sub-contractors
_.❑ 1 am a sole proprieux or partner-
listed on the attached sheet. : �• Remodeling
ship And have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152,g 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (No workers' 13.❑ Other
comp. insurance required.]
•Any applicant that checks box ill must also rill out thew. crion below showing{their worktas'cumpcns aion policy oo11H uiun.
'tlumeuwtnri who submit this aftldavir indicating They are doing all work mud then him outside comrneton must sutunil anew al'fdavit indiwtiny such.
-Conlmctots thm check this box mtut anwhod an additional sheet showing the nalne of the sub-contranors and their workers'comp.policy information.
1 uin on culployer that&providing workers'c•outpencation insurance jar rrty employees. Below is the policy and job site
iufuruurtion.
Insurance Company ?lame:
Policy 4 or Self-ins. Lic.#: —.._...___._--_.____ Expiration Date:
Job Site Address: City/State/Zip:
Attach it 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.'vIGL 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. Iic advised that a copy of this statement may be forwarded to the Office of
Invcsngatiolu ul'the DIA for insurance coverage vcritication.
l da hereby certify under the pains and penalties ufperjury that the information provided above is true find correct.
Siunalure: Data
Phone:7: ----
Officiul use only. Do not write in this area,to be couipleted by city or town official.
City or Town: _.._ Per
Issuing Authurity (circle one):
1. Board of Ilealth 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: --__--._ _- -.- - _--- Phone#:
57V-e Af 7_0 [7'_ rj J as zZ
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."
An 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."
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 compliance with the insurance coverage required."
Additionally. MGL chapter 152, 325C(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-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
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 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 ptrmit/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 he 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 bum leaves etc.)said person is NOT required to complete this affidavit.
the Otlicc 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
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.mass.gov/dia
4
IMPORTANT D O C U M E N T
5
5 5
5 Certificate of , ISSUlame 3.P.5I5tance 5
REGISTERED _ CNU'? He Date of Manufacture 5
5 APPLICATION 5
5 NUMBER INDUSTRIES INC. 03/09/00
5 FI21.4 J2 EVANSVILLE, INDIANA 47711 Order Number 5
5 312193
5 MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to:
5 Z RICE RENTAL CENTER e5
5 TAYLOR RENTAL CENTER S
5 115 CABOT STREET 5
BEVERLY MA 01915-5108 5
5 5
Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California Fire
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial #: 5
5 8023300(l) 7
5 Description of item certified:
5 FI EXF MID 20W X 10 VL WW
5 _ Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 JOHNBOYLE STATESVILLENC Signed: _ � 0 x1 5
5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC.
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IMPORTANT DOCUMENT
5 Certificate of 5 vialw Resista Ne 5 REGISTRATION Is
SUED BY
5 J Date of Shipment 5
rj APPLICATION Q *�MINEW966 06/07/04 5
5 NUMBER s
5
Tent Identification 55 EVANSVILLE, INDIANA 47725 5
FI21.4 MANUFACTURERS OF THE FINISHED 03873714 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5 692825 5
SRICERENTAL''CENTER 5
5 TAYLOR RENTAL CENTER#149784 e5
5 BIEVERLLYY MA 0 91155108 5
5 5
5 _
5 S
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
Schemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial # 8023000 p> 5
5
5 Description of item certified: 5
5 5
FIESTA EXPANDABLE TOP 20WX20
5 WHITE VINYL _ 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 JOHNBOYLE STATESVILLENC Signed: « , ,4•o! 55
5 SPECIAL EVENTS DMSION•ANCHOR INDUSTRIES INC. 5
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5 S
5 Certificate of Paw 3ava'$taure 5
fj REGISTERED 10 CA ISSUED BY 5
5 APPLICATION v s CNOR. Date of Manufacture C
5 NUMBER L INDUSTRIES INC. 03/09I00 7
F1214 7 �k' EVANSVILLE, INDIANA 47711 Order Number I+
5 MANUFACTURERS OF THE FINISHED 312193 5
TENT PRODUCTS DESCRIBED HEREIN
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to:
692825
5 RICE RENTAL CENTER 5 j
TAYLOR RENTAL CENTER 5
5 5 115 CABOT STREET 5
BEVERLY MA 01915-5108 5
5 5
5 i 5 Certification is hereby made that:
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 5 chemical and that the application of said chemical was done in conformance with California Fire
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FR chemical application is: 5
Serial #:
8105660(2) .55555555...
5 Description of item certified: 5
5 TENT WAL 6-10 X 20 VL W W 2/CA 5
5 _ Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric f5
5 JOHN BOYLE STATESVILLE NC Signed: relz 5
5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5
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IMPORTANT DOCUMENT s�����gtn��r�rs��n�nu��LPL�nLpL���� o
5 5
5
5 Certificate Of flame Regimance 5
5 REGISTERED 5
S5 APPLICATION a pf Date of Manufacture
NUMBER INoYHOR® 2/26/99
EVANSVILLE, INDIANA 47711 Order Number c5
5 f� F121.4 M� 0 216154 5
rEr� MANUFACTURERS OF THE FINISHED 5
5 5 TENT PRODUCTS DESCRIBED HEREIN 5
This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
5 RICE RENTAL CENTER 5
5 TAYLOR RENTAL CENTER115 C�
SBEVERLYOT STREET 019155108 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California Fire
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5
5 The method of the FIR chemical application is: 5
5 Serial #: 8105960 (0004) C5
5 5 Description of item certified: 5
_ TENT WAL 6-10 X 30 VL W W 3/CA 5
5 - 5
5 Flame Retardant Process Used Will Not Be Removed By 5
55 Washing And Is Effective For The Life Of The Fabric 5
5 ATESVILLE, NC t Signed:
S e1Z
5 I Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5
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0 �,q�,�PUBLIC PROPERTY
DEPARTMENT
Mwralt c! Y 'O10 130 WwuNc.'Itw sT7 9 .MA0AC n Sk-1-M 01970
TFi 9. 74}9S" Fao 97e•740.9"
APPLICATION FOR THE REpAIR. 1tEMOVA'T[ N CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OC tp�Nry FOR ANY EXISTING
STRUC rnZ OR BUILDING
1.0 SITE INFORMATION
Location Name:Properly 8uilding:
_.. . _.
Address- - - - -
7 ��GLEJ pus �'CG ,� S
Property kt 10CUM In 8;Conservation Arse YIN Hlstorio DWW Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name: GYM Address: 7
ephone:
Tel 9�—7 S
3.0 COMPLETE THIS SECTION FOR WORK IN EYIsIlNli BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation
of existing building New
Bdet Description of proposed Work:
'77�7- 0-0k3D
Mail Permit to:
What is the Current use of the Building? If dwelling.how many wife?----
Material of Building? Asbestos?
"it the Building Conform to Law?
prchited's Name
Address and Phone
Medtsnlc's Name
Address and Photo HIC Registration 0 ---
Construction Supervisors lrceeae d
Estimated Coat o�f�Pro�f�J S Pen*FN Calculation
Permit Fee S--tug=— Estimated Cost X$7/51000 Residential
---- . _ --- Estimated Cost XS11/51100Cornmercial----.- -
- - An Additional $5.00 is added as an
Administrable 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
specifications. Signed under penalty of perjury
Date
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