17 GLENN AVE - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MAy xt 12C WASHING i ON STREET*SALEM,MASSACI WSW 1 is 0197,",
TEL.978-743.9595 • FAX:978-740-9840
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APBlicant information Please PrintLeribly
Nime(Busines/s/OrganizatioNlndividual): 1^T
Address: !`lg n[ n--lrw_V\
City/StatG7lp:k / Phone #:
Arc v an employer? Check the appropriate box: "type of project(required):
1.<I am a employer with 2- 4. ❑ 1 am a general contractor and I 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. : �• Remodeling
ship and have no employees. 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 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
camp. insurance required.]
-Any applicant that chucks box itl most also lilt can the section below showing their workeri cumpensation policy infurnution,
Itomeuwners who submit this affidavit indicating tlscy are doing all work and then hire outside conuoctom must eubmit a new afflidavil indicting.such.
Conuxntn that chuck this box most attached an addilional sheet showing the name of the sub-contractors and their wurkeW comp.policy information.
1 tun can employer that is providing workers'compensation insurance for sty employees. Below is the policy and job silo
information.
insurance Company Vane: _��-CD-V�. _�1(\,5_,.__
Policy k or Self-ins. Lic.#:./IQ f CP9 - T5-7 (_X,369 - I)-Q�Expiration Date: c3 d
Job Site Address: 1-7 G�f.C\C,, cliV l: S City/Slateizlp: sC&M
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 uC NIGL c. 152 can lead to the imposition of criminal penalties of a
tine LIP to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of LIP to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coveragt:verification.
/do hereby certify under the pitins and penul ies of perjury that the infonnutlon provided above is true and correct.
Sienawre: _ -�\.C_A_lLkC-,� s Date: -7 ' I CD ` d7
Phone:i:
O ichd use only. Do not Ivrite in this area,to be completed by city or town ojficiul.
City or Town:
Issuing Authority (circle one):
1. Board of Ilealth 2. Building Department 3.City/forrn 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."
:1n 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."
h1GL 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, §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 nnnber(s)along with their certificate(s)of
insurance. Limited Liability Companies (L.LC)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 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 permit.: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
(i.e. a dug license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Otlice 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
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of viGL 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:
(name of hauler)
I'lic debris will be disposed of in
Marne of facility)
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AUL—ICATION FOR THE REPAIR REND 411 N O.NSTRUC` ION
DEMOLITION. OR CHANGR OF USE OR CL��NCy FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: gui
-
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Property Is located In a:Conservation Area YfN�_Historic DW—bld YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land )1'C
Name:
Address:
-mac
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EX18IIMG 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 I
of existing building New
adef Description of Proposed Work:
CAr\S",moo� E3` x
0-cR� STa��g p �ktSJ� RQ �fl�1�
-- - - -Mail Permit to:
What is the current use of the Building? units?
Material of Building? it dwelling.how many �—
Conform to Law? _ Asbestos?
"It the Buildup Can
Architects Name ( )
Address and Phone ( „A Q
Mechanie's Name
AddressandPhone�ti8 0.tNlAk
Construction Supervisors License 0QCo ( g HIC Registratbn tr
Estimated Cost of Proled S 5000 Permit Fee Calcul-11'
Estimated Cost X$I/$io00 Residential
Permit Fee S
_ Estimated Cost X Si"1000 ComnwcW ----- -
_ An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are property 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 perlury
Date 7 ' I f- 0-7
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