3 HENRY ST - BUILDING INSPECTION (3) CITY OF SALEM
(Ss- PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of M. GL 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 %IGL c
1 t 1. S 150A.
The debris will be transported by:
(lame of hauler)
The dcbr1is will be disposed of in
tn:urrof facit�ty)
��ddfCS, JI (ait��Iy)
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rilslai�RI IiY URI1t:ULL
MAYOR 12C W ASH1NG fON STREET tr SALF-st.MASSACI It NFrI5 01970
TEL 978-74 .9595 Is FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aunlicant Information Please Print Leeibiv
Name tl3ucuwsygrganizationtlndividual): O E2E: � l (,nag 1"i[ L_
Address: I L,4l-C 5T,
City/StatciZip: 1- Y t ��(, Wig Ol2 )hone #: 'T�—g 7-CD ELF
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6 ❑ New construction
employees(full and/or part-tine).` have hired the sub-contractors
2.2 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
requiretiJ officers have exercised their
!0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ 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
comp. insurance required.]
-Ally apphcam than chucks box el must also fill out the union below showing theit worker'cumpensmion puficy inhrrrrutioR
t I Wmcowners who submit this Affidavit indicating they are doing all work and then him outside contractors mwtt submil a new alydavil indiening uich.
:C,mim tore that chock this box most attached an additional sheet showing the narue of the sub-contractors and their workers'cornp.policy information.
/am on employer that Is providing workers'compensa ion insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy is or Sclf--ins. Lie. #: ------ Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of site workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL 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 if day against the violator. Ile advised that a copy of this statement may be forwarded to the O ice of
lutesngutiuns u1'thc DIA for insurance coverage verification.
/do hereby certify t t rr life pains a rt a"al/k. perjury that the information provided above is rue and correct
Phtn:c:i: t'g- LW Z __�_4L4
Official use only. no not write fit this area.to be completed by city or town ojjichtl
City or Town: _- _ Pcrmit/l.iccnse#____
Issuing Authority (circle one): -- -- _ �- -
l. Board of llcalth 2. 1uilding Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector li
6. Other
CunWci Person: Phone
i
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."
btGL 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 rill 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 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 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 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 pcnnit/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
(i.e.a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Otlicu 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
Offlee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
Revised 5-26-05 www.mass.gov/dia
PUBLIC PROPERTY
DEPARII4I&NT
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APPLICATION FOR THE REPA IR RENOYAM N CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE R pC mAN.-y FOR ANY EXISTING
STRUCT[JRF' OR ELm RNA
1.0 SITE INFORMATION "
t ocatlon Name :� 1 Imo( I� T, Building.
Property Address:
Property Is bcated in a:Conservation Area Y/N Historta Oletrid YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 1- -\.l 1 4i.L C�
Address:
e7 'VIA . I^/1�c C) t q
Telephone: `tS
3.000MPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing 2—
Renovation
✓ Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per Floor (sf) Renova
construction or renov led
ation I Z-0
of existing building New
grief Description of Proposed Work: /
-- -- Mail Permit to: Idn ,n-,1 —
`.� t l v
i
What is the current use of the Building?
� C� )
1 7> if dwelling.how many units?--
Material of Building? 5 � s
Will the Building Conform to Law? � — Asbestos?
Architeds Name (�
Address and Phone ( LL 1-
Mechanic's Name t' LILG �'��gCs yvk O l9 co
ddre Supery
and � csse Un a O�1 S�G�HIC Registration 0Construction __-----
Estimated Cost of Project 3 q,O CO permit permit Fee Cftinfion
�3_ Estimated Cost X$7/S1000 Residential
Permit Fee: Estimated CostX s1 V:1000 ComrneroW-___- -- ...
An Additional $5.00 is added as an
AdminMmfdve ehargs-
Make sure that all fields are properly and legibly written to avoid delays In Processing-
The undersigned does hereby apply for a Building�P/ern
ific ft to uild to th a ted
specations. Signed under penally of Perjury /�
Date
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sly,
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