7 HERBERT ST - BUILDING INSPECTION (4) CITY OF SALEM
PUBLIC PROPRERTY
0�7
DEPARTMENT
iUxtnrRISY DRIK;ULL
MAyoft 12C WASHING I ONSTREET • S.UL•W,MASSACIII.S11ISGI97.
,rEt_979.745-9595 • FAX:978.74e-9S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information > G,� p/ Please Print Leeibly
Name(BLisitxss/OrganizatioNlndividual): z( j�r /� TT[y A6 G' r'
Address: _gyp
City/Srare/Ziw cG Y Af,01''- OI qZ Phone 1'': 6 (7 -Z7z 6 /U
Are you an employer? Check the appropriate box: 'Type of project(required):
L❑ I am a employer with 4. ❑ a contractor an I m a general conttod 1
G. ❑ New construction
. ,'at
(full and/or part-tine).` have hired the sub-contractors
_ listed on the attached sheet. * �• emaieting
� 1 am a sole proprietor or partner-
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 S. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MG 1 LE3 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.]
-Any applicant that chocks box al most also fill out the section W-uw showing their wurkunx'cuntpumutiwt policy information
t Ilomeuwners who submit this affidavit indicating Ihcy are doing all work and then hire outside cuntraetors must submit a new affidavit indicting such.
�Comractum that check this box must attached an additional sheet showing the name of Ito-sub-contractors and their workers'comp.policy information.
I ayn an employer that Lr providing workers'compensation insurance fur u+y,employees. Below is the policy m+d jab life
iujorotation.
Insurance Company Name:
Policy a or Self-ins. Lie.tt: __...__._. Expiration Date:
Job Site Address: City/State/zip:
Artach a copy of the workers'compensation policy declaration pate (showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of NIGL 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. lle advised that a copy of this statement may be forwarded to the Office of
httestigations ofthe DI or insurance coverage verification.
/do hereby certify FiWerlepain uad pen t'•s perjury that the(afunnul(an provided above is true nuJ correct.
Dat :7Z
Official use only. Do tool write in this area,to be completed by city or town offiriul
City or Town: _. _ ._.____.._ Permit/License
Issuing Authority(circle one):
1. Beard of llealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: ._—_ Phone it:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empforee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
:kn 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, §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 suh.contractor(s)name(s),address(es)and phone nunrber(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 contirntation 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 pennit/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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
'I he 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
OMee 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
NACL Nt.rti!'KOM:UI I.
St.,u,K t]C WA9QVC:ONS:'AEET •5AL!:%1, Stas.u:>u u:i u;.9iC
TFI:9M743.'1595 •F.#-(:979.74G9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 C11*1R section 111.5
Debris, and the provisions of vIGL c 40, S 54;
Building Permit 0 _ _ -_ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 1.50A.
The debris will be transported by:
— — (name of hauler)
fhed� w( lbedispos-edot`i� -
Aa
(u:unr of facility)
— lalt�(rell Qf(3l:(Ily)
I
` aon
-ate --. .
BOARD OF BUILDIN.O REOUTATtONS c
License: CONSTRUCTIONSUPERVISOR
PNumbeC�S 094570 '
Bir[h(1�e O@!1`5N 947 ,. rs �
�} Expires 091�5/20u9 Tr. no 94570
_ RBsfriCted '�" r
LEON J RACZK�'Ol�l
36 SUMMER STRE ,,,• ;.
SALEM, MA 0191O.h`"i.,} Commisalcrter �''
GI=OF SIT MI
' PUBLIC PROPERTY
DEPAR"I11 &NT
/:IWIFJl.6Y D�.ery
MAYDe
M&r&74i95"•FAX 978-740-9646
APPLICATION FOR THE REPAIR. RE MAMMA CONSTRUCTION
LU
DEMOLITION, OR CHANGE OF USZ OR OC MANCVI FOR ANY EXISTING
STRUCTURE OR BUILD-M
1.0 SITE INFORMATION "
Location Name: -7 W-P L,>C-70!n Building;
--
Property Address_ -- -
Property is bcated in a:Conservation Area Hbtartc Dietrlct
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: I'70Izo
Address:
Telephone: V76 ZY4
g0emolidon
TSECTnIONWORK IN Pylairmt2BUILDINGS ONLY
ExistingNumber of Stories Renovated
New Existing
-] EY O .
year of Area per floor (sf) Renovated ]
nstruction or renovation I �jexisting building New
Bdet Description of Proposed Work:
gvCC� 64 1�i4T6-E- (/mot L�I�T�
P,544c.�-- Fi4t- A- —Gi4--
-- -- Mail Permit to: -
R-
What is the current use of t Building? If dwelgng,how many units?_�_ v
Material of suilding? Asbestos? b —
WiN tM suMng Confo^n to Law? —
Architeas Name _ ( )
Address and Phone G� 7 S
Meehanie'sName o_, �� wiY1 l 17—Z7 Z S 7g 7
Address and phone 3r Z/w
Construction Supervisors License N o s O�FnC Registration 0
stimated Cost ojed S /95'80 pent Fee COMP-MOE
s*m Estimated Cost X$7/$1000 Residential
permit Fee S
--- -
Es*natsd Cost X S11/51000 Commerela4---- -An Additional$5.00 Is added as an
Adminis"WO
Make sure that all fields are properly and legibly written to avoid delays in Processing-
Building
undersigned does hereby apply far a Building�p[ertnR bui to the above to
spgcftations. Signed under penally of perjury /� 7
Date
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