300 HIGHLAND AVE - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MAYEst Jr.Vrnstsl2%GT0N SraktT a SALEM,Mns�vu n a7 t n O197Q
'fra_978743.9595 a FAx:979-740.9916
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Atiollcant Information /� Please Print Legibly
Name lauu rga ncu/Onizationilml vuluuq:--� %?vt /-- !A&C r
Address: / Z% �O/Ylo+ I �i C �siL L/ �h"
City/srarcizip: 19P/2`/fYL -AA GZa" Phone#: 261 3;-6 63 &el
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general eoWractor and 1 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-cuntracton
2.❑ I am a sole proprietor or partner- listed on the attached shceL t 7. ❑ Remodeling
ship and have no amployeas Thews m&coiwaeters have - S. ❑Demolition
working for me in any capacity, workers'comp,insurance. 9. ❑ Building addition
(No workers'camp. insurance 5. ❑ We are a corporation and its
required.] officers have cxercL%W their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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. inssuranca required.]
-Any upplicaut that checks boa 01 MUSS also till tam She"CUM hdduw t[towima lhl*wwkma'wmpanudion policy infi.rmWwa
'I1W uwlRrs wbo submit this affidavit indicating a"ale doing au walk and that him outside comisrlers must submit a aae amdavil inditamina suck.
:Contractors that ch=k this box must attaehad as additional Anent slowing the name of the ab�nlraalon and their warkaro'comp.palmy infamaaun.
I um an employer that Is providing workers'competasadon hasarancefor my employees. Below is the palky and/ob sire
information.
Insurance Company Name: ---
Policy 4 or Sclf--ins. Lie.0: _ .. ... ..__ Expiration Date:
Job Site Address: CilyiStateizip:
Artach 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 uf.MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonincnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be turwarded to the Office of
Inv,angalions ul'thc DIA for s'iosursssarce coverage verification.
I do hereby terrify rurde pund p nultfex of perjury that the information provrded above is trnt gild correeL
tii,•a:uuret ___ Date• X y7
Pht aw a:
o/J7cial gse wdy. no not write it$dos area,to be coanpleted by city or town o/J/c iai
City or'rown: _-. Permi/License q
Issuing Authority (circle one): —_
1. iluard of liealth 2. Building 0cpartment 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Olher
Contact Person: _ Phone tJ:
L
Information and Instructions
Massachusetts General Laws chapter l52 requires all employers tto�provide a workers'anothercompensation
any ctheir
n ttraet of lu�
Pursu nt to this statute,an employes is defined as"...every person
etpress or implied,oral or written
Art empfoper is defined as"an individual,partnership.association,corporation or other legal entity,or any two or more
of the foregoing engaged m a joint enterprise,and including the legal representatives of a deceased employer,or the
association at other legal entity.employing employees. However the
receiver or dwelliusno of ao se having
of more
ah a ts and who resides therein.or the occupant of the
owner of a dwelling haunts having not more than three apartments
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds ar building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 132.§25C(6)also states that"every state or Weal licensing agency shall withhold the issuance or
renewal of a Ikense or permit to operate a business or to construct buildings In the commouweslth for nay
appUesnt who bag a"produced acceptable evidence of eompuzom with the insurance coverage required."
Additionally.MGL chapter 152, §23C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfocnwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
please 611 out the workers' compensation affidavit completely.by checking the boxes that applyto your situation and,if
necessary,supply sub-contractor(s)name($),address(es)and phone numbes(s)along with their certificates)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 worker'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 low or if you are required to obtain a worker'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self.insurance license number on the a 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 fill in the permit/liceue number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
t i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Otliec of Investigations would hie 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
O®ee of Investtpdow
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
Revised i-26-05 www.maw.gov/dia
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PUBLIC PROPERTY
DEPARTbIENT
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N"Volk 130WASUNGrM!'%4 •SMEKMASUQ/L LM0I970
147_976-745-9M•FN¢w8.740.9W
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTINCI
STRUCTURE OR BUILDIN .
1.0 SITE INFORMATION
Location Name: l�fLfh Uy�dv n f Building:
Property Address:: O CT Flk.,-6
s/a'/e,-' q- a�y7a
Property Is Waded in s;Conswvatlon Are@ Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION pv
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIIN3 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work: fie fi U/�
- -- Mail Permit to:
What is the current use of the Building?
Material of Building?
If dwelling.how many units?
win the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Constriction Supervisors License# HIC Registration#
Estimated Cost of Project S - Ul G U Permit Fee Calculation
Permit Fee S - Estimated Cost X$7/51000 Residential
- - - - Estimated Cost $11/51000 Commercial-=------- - .
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date
of
N
0
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