389 LAFAYETTE ST - BUILDING INSPECTION CITY OF SALEM
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PUBLIC PROPRERTY
DEPARTMENT
col\la:RIF.Y UarSt:ULL
MAVoa 12C VrawlwravS EaT*SAL".Massyr ln.xt I n0197
Tht:978.743-9595 •FAX:9M740.9916
Workers' Compensation Insurance AMdavit: Builders!Contractors/Electricians/Plumbers
Analicant Information \ Please Print Leeibly
Name ii3uaim:ssiorganirationrin4ivulwtn:
Address:_
City/Starcizip: Phone #: cr4� �^5N�
Are you an employer?Cheek the appropriate boa:
I.� lama employer with rl 4. 0 6
I am a general cm-, for and 1 . °f project(required):
empluycm'�u arultor part-tine)., have hired the sub-contractors ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet : ?• ❑ Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. workers'comp. insurance
(No workers*comp. insurance 5. 0 We are a corporation and its 9• ❑ Building addition
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 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 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.0Other
comp. insurance required.)
•Art�pplicma that chccka box#1 muse alto fill Mn the section below lowing tbafr worktas'cumpansatpnn policy inionnuion.
' I1u owners who submit this affidavit indicating awy an doing as work and than hirer matide co nmmora must.uhnit a nsw afRdavil inJimaing uwh.
=Cuntrxwn that c1mck this bane rout attached an additional Ansel Jawing the name of am seb•contracton and their woken'comp.polity infhmariue.
/am on employer that Is providing workers'compenraden htsurauceJor my employees Below is the policy and Job.Vile
iujurmariam.
Insurance Company Name: Q o �4_\ Z ti
Policy 4 or Sclf-ins. Lie.n: Cl -� 'C 1 \�\__"_ Expiration Date:
10b Site Address: _ —,L1tht �--h���lz".� �O R
CityiSlate/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and espiratioa date).
Failurc to secure coverage as required under Section 23A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year{mprisonment,as well as civil pcnallics in the form of a STOP WORK ORDER and a Rne
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be lorwarded to the Office of
luveaugatiorts ul the DIA for iniura'ncee/coverage verification.
/du hereby certify under r$45
td ujpedarY tha!ilte iajormatlon provided above is true and correct
tiiu:rnturc: __ Date.
0 ` ) 7b
Oflicial use only, Do not wr/ie in this area,to be,completed by city or town oJJlei"I
City or'rown: Pcrmit/Liccnse A_
Issuing Authority (circle one): —
1. lloard of health 2. Building Department 1.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cunluct Person: Phone p:
i
Information and Instructions _
4
ir
hlassachusetts Gcneral Laws chapter t 52 requires all employers
tom ovide the serviceworker anothercompensation
pesdu any contract of pursuant to this statute,an employee is defined as"...every person
e,ptess or implied,oral or written."
An employer is defined as-an individual.parmashiV.assocutaolk eorpaation 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 Ito entity,employing employees. However the
owner of a dwelling house having not mote than three apartments and who resides therein,OF the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work oa such dwelling house
or on the grounds or building appurtenant thereto shaU not because of such employment be deemed to be an employer."
biGL 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
applleaW who has not produced acceptable evidence of compUaaea with the Insurance coverage required."
Addititmally.MGL chapter 152,$2SC(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any conuact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicant
please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary.supply sub-contractors)name($),address(es)and phone number(s)along with their cenificate(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•umdavit. 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
.elf insurance license number on the appropriate 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 applicanL
please be sure to till in the permiblicerue number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicease 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. When a home owner or citizen is obtaining a license or permit not related to uny business or commercial venture
i i.e.a dog license or permit to burn leaves etc.)said person is RIOT required to complete this affidavit.
N,; Otii:c of Investi;atiuns would like to thank you in advance for your cooperation and should you have any questions,
please do nut hesitate to give us 2 cull-
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMM of lsvestiptloaa
600 Washingtal Street
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Rmvised 5-26-05 www,nlass.gov/dia
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CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMI ENT
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aL�ua t'l'N.�9tN::Jt►S7ElTri�t:y.�vt�ta.ttls.:�.
'ib:w0►I�a9t!�F•�c�7eJ�6'telf,
Construction Debris Disposa t Affldsvit
(required for all demolition and nenovadas we&)
in acconhmc w ith the sixth edition of dw State Building Code.7110 OAR section t t t.S
Debris.and the Provisions of vtGL c 40.S Sk
Building Pamk 0 - _ is issued with the coed tim that the debris resulting has
,his wort shall be disposed of in a property licensed waste disposal facility as dented by.%IGL c
l 11.S 158A.
The debris will be trans
ported by: \
Inrrntt Jf ltaul� `-'7
rho&-bris will be disposeed of in
(ilaa w of ramGty)
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PUBLIC PROPERTY
DEPARmm[&NT
u...srromarl
1399rAounel�yr s7tiar.UU04 MAMAG&AM 01970
TIL' a•746-M 1 FAM W&7404M
APPLICATION FOR TM RUA ONQ'*QiLCrrnlli
DEMOILMOM Olt QMNGZ OF U9z OR OCCUPANCY. FOR MY KMMTMG
1.0 SITE INFORMATION '
Loaatlorr Name cN,�s
Property is kxatbd ln a;Conservaoon Am YA%.Hk+brlo Distld
S.4 OWNERSHIP INFORMATION
9.1 Owner of Land
Name: Q r�
Addrnw
TeW~.
3.000MPLETE THIS SECTION iron WORK IN F]palV
Addition
Renovadon Number of Stor
Change in use
Dem*Udon ExismApproximate year of Area per noon(aconstruction or renovationof existing building
Boa!Deseripdon of Proposed Work:
--- -- ---Mail Permit to.. -
use attheSuUdrq� p —
dd Buis to m? It dwoov&�MOM urmaterld �
to Law?
Asbestos
WI/die&jwq Conibtm '
Ard*sds Nsrne t
AddroM and PhOM
MG&Arms No M
Address end PhCM HIC Rego 0
Cawftcon Supsnksors L�icerdw d,-
Es*nded Cost of Praod Psma Fss CalaaNtlon
Permit Fes f )3 0 O Estlmatsd Cod X$71$1000 Reaidentisl
E$*rAWd Cod X$41/:1000 Canrnereis4--- --
- — An AddU o d WOO a added as an
AdminldrdMe
sure that all fields are W.Perb and WgbN written to avoid delays In pvc"sing.
The ur,UnW,d do"Eby apply{or a BuUding pw"to build to the above stated
sue, Signed under Penally Of PwJLO X
Date D ([
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