34 HOWARD ST - BUILDING INSPECTION L.
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PtEDi!TO A.PEttt W BOW GRAWkD
CITY OF SALEM
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W) 600 Wasfifw0toa Street
Boston.MA 02111
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Worker'Compenadem Inatrance AfNavk:Bn�denlCoetndon/Eledridamlllamben
ApedcaidInfamadAll Please hint L NOW
Name , I�tIW l
Address:
CitrAwwipe �SA'L l �y29' Phaoe : /— YzNq
Are y empbyaat cbeektbt,Opeapriatebnss Type dProjed O"dred}
1. I an s asployw vi ilk � — 4. ❑I.,,meal aoetr,etar and i ❑New condmcdoa
emptoyeee(frB aodi«v��>• Ism circa do aaD oo tra -M
2 ❑ i am,ease paspridor or puma ]lased on me atmebed Am t 7. {E`Femodd5ng
ship and hats an employees Tame sob-c onvacow have L ❑ Demolition
woddtp forme is OW eapscigr. wodww cot*inum ston 9. ❑Wilingaddmoa
wodwW col 3. ❑ We ae a aaspmadoa aid ita .
of em hove cunbad tbeir I&MIbeeieal upsks or additions
3.❑ I ant a boumw*40149 20 vmk rWI of a woodw par MGL 11.2fhmbiud np*s car addidoae
myset(No vadwo'comps a 15Z 11(41 and we have no 12.� hts oofn a
msotseo0 )♦ cmpbyam'Pin wadm,w 13.0 011W
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;Any
HOWA w�T&AM& itft "11 .ra�ae�/OWYMdo�dds48.ba[.adMMWVAVAdh - nwdntwi .III vk: scoL
gConewtow ar cbwa aibox me dumbed a ddhtmd drat ebmind 90 MM ofar wAamanews and filar wmtaa'amp poser afornstdoa
rem as expieydr daf k providla{wor4ns'eearprasdolas burrower for wry easpleyaa Aden b AUjuallq ead job sbe
byerwwAra
Inamaooa0ompemyNsme: �C`( / �JcSl7R-A�Gt✓
Policy 0 or SeWas.Lic.t{: Expaadon Dan
Job Site Addtac City/StaONZip:
Attach a cow d the workers'compandon po ft dcetaratl,n pale(d"Ing the poliq aembw and a*ulon date).
FWlmv to Awn aoven®e as fequbvd antler Section 23A of MGL a 152 can lad to the iopoaidon ofcrhuW peealda of a
Hoe op bo s1,5110.001 wimpfiaoas,eu4 as well a civil peoahin in she fium of a STOP W=ORDER and s fine
of op to S250AO s d against Wor. Be advised do s copy of dub statemes my be Sorwuded 10 tlse Office of
iavati tdooeoftbe for covempVotifladaa
smommommmommomm
I la Aw"y ears fAepabu and pera4tae aJparlrq alas slot biJbrssastsw prerJlad abaw is acre and awrrea:
7 Q 8 2s v
Qfti sl NU cab► Do eat weft fit LU errs,to 6e evapr'a0r/b dD'M ass+a e.0fefiL
Cky or ra m rermk/Ilaase tr
Int ving AWborily(drek oess)s
I.Board of Health L Butidfag Deputmenl I Chyfrows Clark 4.F.bddcsl lnrpedor S.Plumbing lospeetor
L UUM
contact rersam Phone s:
Maaachasetsr General Laws chapter 152 requires an employes to provide wafer' oouepensaaoa for MGM �W-J—
pumaa,10 mia st"Ni an ergpmym is dcfaW s"...evaY Pesos is the of soma under 3"coaawd of bite,
espraa a impli4 oral or writma"
As orpbysr it de6sed as"as individual.prtoeabip.astoeiados`corpondom dr other legal c0ft err suy two or more
goes a joint aaepri�a ad imeje t�as� a da deoeMsed eerploya.or ghee
omcciva a tt m Gtm ��'assod3dtioa of omen u a emty,employing CnVbyeea. Howeva tb
hooaa bavtet sot mere tW Arse tpsto msa and wb raider maeis6 a as oovapamt ddW
dwelling Rouen o mot weer who eogbYs Pasoan a do mrisscameM aomosceas err rem we*OR inch dw cftg Ws
or Qt ib aoaodt abnt7dmg MpOarteeset AvaeiD ad am because of ns&aopbymatbs deemed in be as m4b'YQ
haM tb beans"or
hiCJL cWW ,52.4�d)also m so ant oum7 again as,land�sK Mpeg�wltb
renewal d s seem or pwrok is oPeamie a bsdsasa ea to a aMruet bell"`tb cemamaswda for sap
appreasel wb W Mt psodeeed aeceptMdM vevidamse of eomp"m w1a tb hmuv ee nave iv regelyd.'
Additionally,NM ehapats.152.123C>(T1 mom"Neimtr ere aomancowealta mr any of is pal"salmvidotta abaft
tar Ave paWaee dpablie wod uanil aoeeptabb ewi Isom of cOmP�win ascow im may inaataaoe
of"ehapm have beam praeamd loam cominding ado '•
pkase f m oat tb worker'oompadatba affldsvk oonVkt*t by c3echhep the boas eat apply a year sbasdon and,it
neoawy.supply )name(al Ab as(a)and pbae mmbaO)Muni wuh their mdficam(s)of
inaaaeoa. Limimd Liabft cnVW s ULQ a Lhumd WOW Paaaabips�win no=00yea omen dam as
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members a psrmaa,sea not togmtred a aeY woekem'oompematiea ilssuraaoe If am LLC a L1P doe bave
cmpbyW16 a policy is regehed Be advised ant this affidsvk may be mbmitsad a ere Dqw m d of lnaostaial
Accidents fitr emfhmiedcs of inanasce oovaW Alas be sus to alp said date the affidavit. The dWWk ehomld
be gemmed to ere clW a town art&r application ix tb Permit a Soma i being requam4 ant ere Department of
lnduamial Aocidam. Sys You Dave ow questions reprdisi Ave law or rfym m regp¢e I u►obtain a wedws' melt
wnipensetionpotiey.pleetu4 can ere Deperemas at ere zo>erber listed fiches: SeetFiaauted eomptlaia should ease
self-boom tlasse samba on ere appropdsgs Thra
Chy a Tows Ofndsb
plane be an ant the affidavit it oomptem and priemd lepblY The Dwarboast W provided a space st ere botsom
of the affidavit for you Io fill art in as evest ere Office of bvadgsdow has a contact you teguft de applicant.
Plem be aura a tilt is the pau Micem nmvber whitit will be used ar a ref am mmba. hr addidoa,an aPylic"
that ma submit a kple pamit mn gp&atieos m my given yew,and only submit one affidavit indicating current
policy mfotmMnon(if mcmary)and under"Job Stet Addrw"the apphcaot shoeid warm"all badoam is (city or
towel"A copy ofew afBdwk that ban beam OdWW r afamped or soaked by tb cily of Iowa mqr be provided Io ere
a p*of g"a valid dffidsvk it of Se ffw lbea pamiee a liccom A sew affidavit tma be MW out etch
year:Where a Dome owes 9<cidaea is oboi imi a Home a Permit not tdamd Io MY busman a commercial veaare
(La M dog license or panic a barn leaver ego.)said pasam is NOT required a eengW Ada slfldavk.
Ibc Office of Investigation would like a&mk you in advance for you cooperation and should you have any questiook
plane do tat hesitate a give us a esfi.
IU Depa runes addren,tekPbge ad fhs mmbea
The CommonweWift of Mamwh»sdfa
of Industrial Atxideeb
O®ve of Invedigat[mi
600*UhKJM Sftd
B09M MA 02111
TCL #617-7274900 act 406 of 1-977-MASSAFE
Fax tt 617-727-7749
Revised 5-2" wwvrr.mass.Sov/dia
CITV ,.OP SALKN9 MASSACMUSW"S
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pvamM by d6 2W3ft Farm iat bs ahpond dbi a p Wa %p Bound aolid^.iaab
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TIM above I=*ropm the debris dns du ds hdov.raoovatioa rabab or odw
akadow of bal ft or ateudm be d wow is a plopsiy659aasd lo"wraw dirposal
b ft as da&sad by lbw,ca SISK and ma buildhVpemitr cc Semi a»a
iadkals dW bea"of td heft.