250 HIGHLAND AVE - BUILDING INSPECTION (3) b1�Mo� OWolt� Y"�ND
r wgwy Lou"to
aOWAMN OolMO Ysk�NO V
BU LD" PWW APPLIM ON POft
PMmit ux
(Grob.hM* M @A*) RDA R- GRI bWM�SWh-O CWWWJM D" Sh4 POOL
PLMU!ILL OUT Lsti19LY a cmnxmv TO AVOW Ours IN PQOO89"
TO THE L49PECTOR OF BUILDINGS:
The WWwrigned hM W sPPWs for s POMA 10 build s000WQ to ttw t'owbV
Owners NMnm iA' �)i A/O
Address& Phi Yb -
ArddleWs NMm
Address d Phone . 1
M achan os NMns i��, �� tea✓PAY / 1
Address& Pho _66
eat is sr pmpm d wYOrrpP �is:M me I-
Md"a twss al r•srrar I for now WAW wwrw�.�----
wr b"O oo *=to bR ?
EtsMMd aott � d qqr tJonw• N �'` strto uotrw•_f��
XIse. I agree. o APPib.nt
9gNi0 UNM THE Pw"TY
OF PwLRW
OE9CRIPfiION OP WOIX TO BE DONE
MAIL PERM9T TO: L.z/L Llo - ,rem I m � cl!_
•
No. �0/ /,7 -_,n
APPLICATION FOR
PElufr TO
LOCATION
PERI►AlT GRANTED
7 Lvp
INSP6 OF euLDl1 8
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information " '` Please Print Legibly
A
Name (susiness,/orgamzatioon/ngndividual): ��✓L tis��' l.+y1 UfOrs
Address:
City/State/Zip: Vein Phone#: f 7
Are you an em to er?Check the a ro Irate box 't`' " a of project(required):
P ,Y. PP P Type P J ( 9 )
1.❑ I am a employer with 4."❑'I am`a general contractor and I 6 ❑Newtconstruction
employees(full and/or part-time).' have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet t 2• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working,for me in any capacity. workers' comp. insurance. f 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10: Electrical rep airs or.additions
required.] t s. . officers have exercised theirs ❑
• or additions
11: Plumbing repairs add tr
3.❑ I am a homeowner doing all work right of exemphon'per MGL ❑ g eP
myself. [No workers',comp. c. 152,§1(4),and we have no 12.❑ Roofrepairs
insurance required.]t: employees. [No workers' 13.❑ Other
comp. insurance required.]''
*Any applicant that checks box#1 most also fill out the section below showing their workets'compensation policy information:
t Hotneownen who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
lContractots that check this box must attached an additional sheet showing the name of the sub-caattectots and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie. #: _ �� Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy.declaration.page(showing the policy number and expiration date).
Fail=to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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 coverage verification.
I do hereby certify nder t e painsptrd penalties of perjury that the information provided above is true and correct
Signature � ,ut�l.l� Dater
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town 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."
y -
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,y ,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 'r
dwelling house of another who employs p'eisons'to do maintenance, cor&nictiou 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 eavloyer."
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 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 pernvt 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 i
Please be sure that the affidavit is complete and printed legibly. The Dep"ent 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 fill in the pemnttliceimse number which will be used as a reference number. In addition, an applicant
that must submit multiple pemiit(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. Anew affidavit must be filled 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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office 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,teieplione 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
w
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
40 SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildin¢ Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of Applicant
ate