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23 JACKSON ST - BUILDING INSPECTION ti a ►400�a rw_.�,X t�t�•a ��LSaEkS�� ST, tr HwoAr olilMet'► a @Loa"PMW APPUCAIM !Fora (CUob whiolwwr appbl (11 ook��.awks Conrad Y TO AVOW OiLA1fi MI r110CiMIMa PliAit lLL.CYO ?0 THE IWBP6CfOR OF BIALDItiOS no U!"e pn�d hsr* wpm fora Pow a build rrooadYp w to bow" 0 ww/PNAOMMO S 4j em, AddMU&Phm c3 3�teKSorq S7'' 019-70 � -sag"go44 AIOMWct'rt IIN , c clone Address i Phpl� .¢wa r K�� 2d• P�obocl�/ , MA. l�l S� p�ac�o Wduffift NNW c � Addrw•PhOW Noblepu9anaar OM� $(ntcle �m l✓ wtw a attest �.drMb�ar iww tts�Il � 1Mr M�ioldolsl to art `' � 3,= N a tat. .• ©s4g Spa ir�d ooM 5 Cy utMw• agoo Lie. , XWjiga of �Via Pw"tY oP POPAW DWMW& f M of VIM To W DW l P ( ref0JF �MA,'nl D�c((/ MAIL PERMIT / C, C i�S712 Co u STc�cT v n/ C Ca-- W✓�lK�({ l2v� tl C4StN�-( Wth 6l�UO APPLICATION MR Pww TO LOCATION PEF"T GRANTED ' The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Let=ibly Name (Business!Or�oization/IroividttaQ: -� C A-STI-e CO A. ruCT" A( Co- ivuc Address:—4- l,J 4-((<•e r City/State/Zip: A� y`'!1%iA C) t(4 Phone#: 175 ?4o- S 14o Are you an employer?Check the'appropriate boa' ,. Type of protect(required): 1.® I am a employer wiih t 4. 0'I am a general contracoor and I 6. ❑New construction 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 ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working;for me in any,capacity. W'ork�' comp.,instvan% 9. Q Ming addition [No workers'�P.insurance . 5. ❑ We are a corporation and its. required.]_ officers have site creed their 10.❑ Electrical repairs or additions 3.❑ I am a homecwnerdoing all work right of ex empuon per IoiGL- 11.0 Plumbing repairs or additions myself. [No workeW.comp: c. 152 1,§ (4xand we have' no 12 Roof repairs insurance regnirod]t, employees (No workers r q ' 13.❑ Other comp.insurance uiied. •Any applic®t that checks box#1>m st also tip out the section below showing the¢.wotl<sm'conwcanpon policy in&mut6L* f Homeownm who submit d&atrtdavlt indicating they are doing all work and then hhce oatmde conft4ma iiiuet submit a new affidavit indicas:ing such tronnaMo Met cfiakthisbox'=4 attached onedditiosatsbeet&OW'n&themme.oft M&oonRectorsandgtehwmkm'comp.poicymfomtefioa I am an employer that Is providng rvorkers'eompemadon tnsurancefor myenipfoycet Below is tke po&7 and Job sloe information. Insurance Company Name: T o r P-e U T&I S . Policy#or Self-im.Lie. #:(SSIMS 76 B 7o4oS Expiration Date: 111/310( Job Site Addrrsa:_�_3 SA-Ck,� D T• S 4 2 M ytL4' �}1 q7o (yty/StatelZip: S alp k Mq a t 9 70 Attach 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine cep 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office;of Investigations of the DIA for insurance coverage verification I do hereby cerdfy under the pale and penaft la ofperjwy that the Information provided above is true and correct Sienature• % � o�. , c Date a< 0 Phone#: O,Q'kid use onlyt, Do not w1*0 in thin areo,to be compkred by dry.or town ohkki City or Town: Pernoucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#' Information and Instructions Massachusetts General Laws chapter 152 requires all employer$tic provide workers' compensation for their employees. Pursuant to this statute, an employes is defied as"...every.person in the service of auotber.under any contract of b ir4 , l express or implied,oral or written." Or 10010 An employer is defined,as"an individual,partnership,association'corporation or other legal entity,or any� of the foregoing engagod-in a joint enterprise,and including the legal representatives of a dew� Yhx. or the tion or other legal entity,emp yhng However the receiver or trustee of an individual,Partnership, and wbo resides therein,or the occupant of-the" owner of a dwelling house having not more than three apartments dwelling house of another who employs persons to do maintenance,construction or repair work on.such dwelling house deemed to be an employs." or on the grounds or building appummt 1hereo shall not because of such employment be MGL chapter 15Z §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 commonweakh for any applicant who has not produced acceptable evidence or compliance with the insurance coverage required."shall Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth not any of its political subdivisions n 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-contractor(s)name(s),address(es)and phone number(s) along with their ecru ficate(s)of Companies or Limited Liability Partnerships(LLP)with no employees other than the insurance Limited Liability Come (LLC) members or partners, are not squired to carry workers' compensation insurances If as I LC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for policy i naeq of insurance coverage. Also be,`sure to sign and date the affidavit. The affidavit should be returned to the city or taws that the application for the permit or license is being requested, not the Department of Industrial Acxidems, Should you have any questions regarding the law or if you are required to obtain a workers' d companies should eater their compensation policy;Please can the Depaartment at the number listed below. Self-insure self-inqurancolicense member on the te 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. applicant Please be sure to fill in the permittlicense number which will be used a a�onencely susubmit naffidavit number. In anon,an current that nmst submit multiple permitAicense applications in any given year, policy infomnation(if necessary).and under"Job Site Address"the appiicant 'should write"ail locations in 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 fixture permits or licenses. A new affidavit must be filled out each year.When a home owner or citizen is obtaining a license or Normnot � 1 ete this affidavit commercial to any business or venture leaves etc. said n is required or errant to bum ) Perm (in. a dog license p d like to thank you in advance for your cooperation and should you have any questions, The Office of Investigations wool Please do not hesitate to give us a call, The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of lndustrial 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 CITY OF SALEM9 MASSACHUSETTS • PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978.745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building 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: iYl 7 rKc(� (Location of Facility) 6 i- Signature o Applica� Date