7 GLOVER ST - BUILDING INSPECTION J; CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wIMILI RUN DR15t:ULL
M.xvtrll I2C WA11-01Ne'TON STREET 4 SAIEM,MAslACill.\F.'1-1801M..
'fkl.:978-745.9595 4 F.%X:978-7404846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApD]Icant Information Please Print Leeibly
Namc lau<ittt:ssfOrganizationlindivtAuul): RuLf-I
Address: no Pc�3twT �!
City/SMrcizip: be-+-,nos 1 MA 022di� Phone i/: Ul
Are,you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ new construction
loyces(full and/or part-Lillie).* have hired the sub-cuntractors �,/
2 I am a sole proprietor or partner- listed on the attached sheet. 7• LvJ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. ❑ Building addition
(Iqo workers comp. insurance S. ❑ We are a corporation and its 10.[1 Electrical repairs or additions
rcquiretL] officers have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per MGL f 1.0 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.❑Other
comp. insurance required.]
-Airy uppliwtp that checks box el must 260 fill out the section hctuw Jtowing their workers'cumpensatiwt policy infurmutiutt.
' I Iomutwnrn who suhmil this affidavit indicating they are doing all wort and thm hire outside contrnaon mtutt submit a new amdavil indicting etch.
C'orttrxva'x that chock this box must anachad an additional Jtcei%hawing the name of the sub-contractors and their workars'epnp.policy inftxmalim.
l um un employer that Ls providing workers'compensation Atsarance for my employees. Below Is the purity and job site
infonnarwn.
Insurance Company Name:
Policy is or ScIF-ins. Lic. q: _.._ Expiration Date:
Job Site Address. City/Slate/Zip:
Artach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to wcurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal,penalties of a
fine 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 Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
lavc,ogati•ms of[hc DIA for insurance coverage verification.
I do hereby y under e ' s an fperjnry that the infuraratlon provided above is true and c'orrecs
—
Official use anly. Do not write iu this area,to be f ornpleted by city or town ofjleiaL
City or Town: _-. PcrmiULicense d
Nsuing Authority (circle one):
1. Iluard of health 2. Building Department 3. Cityffosvn Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
G,tttact Person: _- _ _ Phone q-
4
Information and Instructions ,
Massachusetts General Laws chapter 152 enquires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empt"we is defined as"...every person is the service of another under any convact of hire,
express or implied,oral or written."
An emplojvr 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 of trustee of as individual,pattncrship,association or other legal entity,employing employees. 14owever the
owner of a dwelling have 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 prodoced acceptable evidence of compliaace with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth a"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. Latticed 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 maybe 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 low 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
,elf-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 permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense 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
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
1,hc OftiJe 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 Sweet
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposst Aftidnvit
(required fix all defnolition aid renovation work)
In acconiauce with the sixth edition of the State Building Code.7SO CNLR section 111.11
Ocbda,and the provisions of M. GL c 40.S A
Building Permit A _ . _ is isrttad with the condition that the debris resnldng Dom
this wait shall be disposed of in a property licensed warxe disposal facility as defined by MGL c
I It.S 130A.
The debris will be transported by:
_._. tnam of hauler
me debris wilt be disposed of in :
ss�r orb
(same of fecal ty)
..lt.
EITStOF
9Il•
PUBLIC PROPERTY
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DEPARI'NIENT
MAYM 130 WAUWAGTM 91VM YLLAjK HwSLU3asr'1'Is 0197e
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION. OR CHANGE OF USZ OR OCCjjpAN[°Y_ FOR ANY EXIWMG
STRUCTURE OR BUILDING
1.0 317E INFORMATION
Location Name: mt— P f Building:
---- property ----- -- -- ------ --- - - - ----._.-.
- - -
(ov-tr s(
AWwty Is located in a.Conservallon Area YIN Historic Dbkkt YIN
2.0 OWNERSHIP INFORMATION
Z.t Owner of Land _
Name: L czr� v.ei
Address: 'J G/ � Sfi
/e11-14
T
3.0 COMPLETE THIS SECTION FOR WORK IN anATlun BUILDINGS ONLY
Addition g
Renovation Number of Stories
Change in Use Demolition g
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
Mail Permit to: .Sl3Z 02 Al env /�P
What is the current use of the Building?
ma uni
ts?H dwelU how many n9.
Material of guildkg? `V�
VVM the Buitdirg Conform to Law? e S Asbestos?
Architect's Name
Address and Phone l )
IMochanies Name 4, moo
Address and phone
Construction gupsrvisors License ay HIC Repistratbn 0
Estimated 50 of Project
Parmit Fee Caleulatlon
Permit Fee ord Estimated Cat X$7/311000 Residential
EsWnated Cost i41/:1000 Commerda{---------
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fleids are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above ed
specfflcations. Signed under penalty of perjury
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