203 JEFFERSON AVE - BUILDING INSPECTION ��g�t�E fllrEi�YiD APPROVED 8Y TiiE
JdSPIOB Jp'BIDR 7DAP.EB ]'AEJNa GRANTED
CITY OF SALEM
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BWLDING PBRW APPLICATION FOR:
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(Cfrdo whWhowr apply) Roof, InstaY swk- , Cow" D" Sled, Pool.
har•
PLEASE FILL OUT LEGIBLY•COMPLETELY TO AVOID DELAYS W PiWCEEWNG
TO THE INSPECTOR OF BUWNG&'
The wxWscred harobl/ app in for a Petit to bWW aocwdp to tho followirp
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Addmu & Phone 902v
Ard*eds Name
Address a Phone . I
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slOnatur. of AppYcant
8W= IJN =THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT Tfr
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No. YJ-Q6-
APPLICATION FOR
PEFWI TO
LOCATION
3. )eereroh /
PERMIT GRANTED
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INSPECTOR OF UILOMM
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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"
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,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 workon 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 ofpublic 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
msuranm 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 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 limo.
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 die affidavit for you to fill out in the event the Office of Investigations has to contaotyou regarding the applicant
Please be sure to fill in the permit/licensc number which wr71 be used as a reference number. In addition,an applicant
that must submit multiple permit/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 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 burn 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,telephone 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
1-ite (,'ommonwealtit of massacilusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
rance Affidavit: Builders/Contractors/El p
Workers' Compensation Insu lease print Le bl
A licant Information /
Name(Businesstorpnization/Individual):
. 12 u d
Address:
City/State/Zip:
i . 2-;r^--f�2/ Phone#: �co �
ro rate boa: Type of project(required):
Are.y an employer? Check the app .P 4.
I am a general contractor and I 6 New consUuetion
1. I am a employer with have hired the sub-contractors
employees(full and/or Part-time).*
7. [Remodeling
listed on the attached sheet.t Q Demolition
2.❑ I am a sole proprietor or partner- These sub-contractors have $
ship and have no employees workers' comp-insurance. . 9. ❑ But7ding addition
working for me in any capacity. 5. We are a corporation and its
o workers' comp.inmmcc10.[� Electrical repairs or additions
[N officers have exercised their
itched•] right of exemption per MGL 11.0 Plumbing repairs or additions
3.[] I'am a homeowner doing all work e. 152,§1(4);and we have no 12.[] Roof repairs
myself. [No workers' comp. employ. [No workers' 13.[] Other
insurance required]t comp insurance required.]
Any applicantluichecksbox#1moatalsofilloutthesedionbelowshowiadglefrworkers,cocontmctmmunvensation xYibmitIL ew
t Homeowners who sulm0 this affidavit i&icsting they are doing all work and then hire outside conhactorsmust submit a new affidavit indicating such
t H0me0Wrs that checkffiisbox must attaebed an additional sled showing the name ofthc sub-coutmi tm and weir workers'Dump•Policy information
ensation insurance for my employees. Below is the poltc} and job site
I am an employer that is providing workers'comp
information U :� 0
Insurance Company Name: 2 �0
I/]q a S Expiration.Date:
Policy#or Self-ins Lie.#:
�n 1„ 3
City/State/Lip:
Job site Address: p p (showing the olicy number and expiration date).
Attach a copy of the workers'compensation policy declaration age( g p imposition of penalties of a,
Failure to secure coverage as required undue ection Wit, 2 well as civil penalties cas in d to a of a STOP WORK ORDER and a fine
fine up to$1,500.00 and/or one-year imp Be advised that a copy of this statement may be forwarded to the Office of
of up to$250.00 a day against the violator:
Investigations of the DIA for insurance coverage verification. i
fy under the pains and p nalties of perjury that the information provided above is true and correck
I do hereby certi
Date.•
Sionatvre. —
Phone M
F6Other
use only. Do not write in this area,to be completed by city:or town of)xkL
Permit/License#
Town:
Authority(circle one):
rd of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
Phone#:
ct Person:
CITY OR SALEM. MASSACHUSETTS
• • PUBLIC PROPERTY DEPARTMENT
120 WASHINGTOM STREET, 3RD FLOOR
•" SALEM, MASSACHUSETTS 01970
97TANLEY J. UsDVICi, JR, TELEPHONE: 97e.745-989S EXT. 380
MAYOR FAX: 979-740.9849
Salem Bo�dlnn I)sna_.+.++aw�
DChris Dkpffi i 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
y-�3 -ate
Date