2C HALSEY WAY - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
�0O f DEPARTMENT 'M``
heUsi RIF.Y URl9taaLL �/ ' 1 I
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Tat_97L7eS9593 a FAX:9W413198ee
Worken' Compei dfle�usuranee At'lidevit: Builders/Contnctora/Electridans/Ptumben
.Applicant Information
PleasePrint L
Name tw.airns torpnirstioklmuvnanp: Tie ��ir4.t Pi l�i;De_�=�. -,Fe�C,o
Address:
City/St3Wjzi0:_1(P-k* W& C�/ 9�— tuw a: ?P 7 y s 3-21.7V
Are you in employer?Cheek the appropriate bete Type orproject(required):
1.Q 1 am a employer with 6. Q 1 am a general contractor and 1 6. ❑New constrticuon
�mpluyCl ai(roll andtur part-time).• have hired the seb-contractors_ r
2 I am a sate proprietor or partner. listed on the attached shoat : 7• ❑ Remodeling
ship and have no omployces Thom have a. Q Demolition
working for main any capacity. workers'comp insurance. 9, Q Building addition
(too workers'comp, insurance 5. Q We am a corporation and its !0.❑ Electrical repairs oc additions
requircdL) officers have exercise!their
3.Q 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myselt(No worker'comp. C. 152,41(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(A'o Worker' 13.❑Other
comp insurance required.]
•.\cry+pPItcatil lbel a6ucks boa et alder also fie"ads maim lalow ahowiaa their warko'tonepp Mil"pull y in6xmetios
'ljw wtwrs whazabinifthis anfdsvit tadkadal;tlrry me eaters dt wNd sad tam his Oenflde eamri'taa adasl•ulaeit a raw attLherk imlieadina rah
:Ca mgm then eMek this boa mug anaehad cot additional altrst showing 0e nano orals nth their wades'cosy.pahcy sribnaafwa
sssssssa
I um an employer that&provlding workers'compensadon Laurance for toy emp/oytes, Below Is the polity and Job site
information,
Insurance Company Name:
Policy nor Sclf--ins. Lie.0* __. . .._... Expiration Date:
Job Site Address: CitytSlawzip:
Att2ch 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 tit•.IGL c. 152 can lead to the imposition of criminal penalties of s
ri ne up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER snd a fine
of up to 5250.00 a day against the violator. Ite advLicd that a copy of this statement may be forwarded to the Office of
Invsugrauats of the DIA for insurance covcra,e verification.
Jo herby r.ni/y uuJai thr paint and penis/fief o/ dary the the in/brmadon provided above is nut and cornet
tii•aatur- fy. D
U/Jfdd asr oa#t Be sot write fa thb area,to be rompfded by a iyor town oJjfa i"i
Ciry or'fmrn: Permit/1.kcase
Isiuing Aulhurily (circle one):
I. Board of Ilealth I. Building Department 3.City/rown Clerk i. Electrical Inspector 5. Plumbing Inspector
6.Of her
Conrad Person: — Phone N•
Information and Instructions
Alassachusems General Laws chapter 152 requires all employers to provide workers' compensation for thckcmploYceL
Pursuant to thiMF+Rt�an eas/leyee is deemed as'...every person in the service of another under any contract of bite,
eapress or imp l"K oral or written"
An t psptoyer is deflaed a"an ittdividutl,Pattaarship.assoeiadi ss'oorposation or other regal entity.or any two a snore
Of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer,or the
association or other legal entity,employing employees. However the
recover a dwells of as se having patmetx6np. and who raids tsaein.or the occupant of the
owner of a dwelling house having rat rnote teas three maktapart ten
dwelling house of another who employs Persons ro do maintenpnce.cuosamctia►or repair wont on such dwelling house
or on the grounds at building appurtenant thereto shall not because of such employment be deemed to be an employer-*
AtGL chapter 152,425C(6)also states that"every stab or beat lkesdag agency shied withheld the issuance or
renewal of a Uceusse or permf to operate a business or to construct baildlep Ire the eomssoawedrh far say
apptleaM who has set prodead seteptabte evidence of cOOPgoee with the Insurance coverage required"
Additionally.MGL chapter 152,§25C(7)states"Neither the commonwealth not any of its political subdivisions shall
��into any for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting audicid y"
y
Applicants
Please full out the workers' compensation aPldavit completely.by chuxit g the boxes that apply ro your situation and,if
necessary.supply subcontractors)nan*s),addm*cs)and phone number(s)along with their certificatc(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 conflrrnstion of insurance coverage. Also be sure to sign and date the afndavlL 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
.elf insurance license ntmnber 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 full out in the event the Office of Investigations has to contact you regarding the applicant
please be sure to till in the permit/liceuse 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 subunit 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 ro the
ant as proof that a valid affidavit is
applic on file for future permits or licenses. A new affidavit must be filled out each
btaining a license or permit not to any business or commercial venture
year. Where a home owner a citizen is o
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhc O(ii,x of investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us ;'call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of lndustrial Accidents
OAke of bvtltltlptle"
600 washinSton SNON
Bostono MA 02111
Tel. N 617-7274900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
2cviscd 5-26-05 www.mass•gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT `_ !,
...,lar al aY•'alra't 1
>�,,.• tDt:'I.,et�w::�iastt•iu:r.ftvt,tsu ulna::9
Tn.wTs4atdit f-ucOW460 M
Construction Debris Disposst Affidavit
(retitumd for all 3emlition and renovation work)
In accordance with the sixth edition of the Stets Building Codi%7SO C26IR suction I I I-S
Debris,and the provisions of NtGL c 40.S 54
Building Permit A _ I _ is iswad with the condition fiat the debris resulting Born
this wait shall be disposed of in a properly licensed waste disposal facility as defined by%IGL c
1 11,S 150A.
The debris will be transported by:
Iname on haute
rho&-bris will be disposed of in
._ I u.,na of ra,antyl
..ita
ETI'Y OF�X
PUBLIC PROPERTY
DEPARTM&NT
Wra
IJ0WARWwWwYn�t gu V�suawsrTs01970
[�:tr47is�s�s•►4s M740-964
APPLICATION FOR TM oV-M-QY TION CoBMILMM,
D
. �.o alTs INFORMATION •- .
Locadon Noma Suildk :
Prop"Addroow---
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PropwV Is kxetsd ln a; Ym r vn�
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Addreso.
C
Teleph .
l3.0 COMPLETE THIS SECTION FOR WORK IN E7(I MNQ BUILDINGS ONLY
Addklon Existing
Renovstion Number of Stories RwWated y �,
Change In Use New l
Demoodon Existing
Approximate year of Area per now (st Renovated
construction or renovation
o f existing building N@W
Bc d Desc iption of Proposed Work:
pi-5 1/�� PUo� �7 � `� 4"V4
--- —- ---Mail Permit to: -
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MOMW of tlu0dkW7 �:Jo 0 D ? Lo
w Mn qupe 4 Lawn?
Ads Nam.
Addr w and P1wM
Name as
Add "and Phone
Conti&Pmviwra l.ifurtae>r -- HIC ReOkrtra 0
Eylignsted Coat of P►ojaet
Estknatsd Coat X$7/S1000 Resider"
Permit FN= Es*naad Coat X t41 nw
41000 CaaardaL
An Additional$5.00 I•added as on
Admkdsra#ve dwg&
Make sun that aY fleide are pmped r and gbh wKitten to avoid dektys In P mCS"IrO
The wxWnW ed does hereby apply for Al Buiidktp Permit to build to the above
specNl=*xm sWod under penalty of Penury
Date
a� oti -