7 LAURENT RD - BUILDING INSPECTION • ,�Slf/-off CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�I\IaFRtF.Y URtlt:ULL
M\Ylne 12C WASee.4:70etsmEirr a SA bast,h(ASIAcan.xtrrsOt970
'ftsl.:97$•745.9595 a F.ax:9M740.9a46
Workers' Compensation Insurance Affldevin Builders/Contractors/Electricians/Plumbers
analicant Information Please Print Legibly
Narric sinesslOraalsinriodltallvtdlwl): �/:// �oitri' /69 OIS6.er /`
Address
City/StaslziP: ,a x ,,-.rr - Alf. z >
Are you as employer?Check the appropriate boas TyL
or project(required):
1.0 1 am a employer with 4. 0 1 am a pour)couUWWr and 1 6, Newconstruction
employees(full and/urpsrt-tine).` have hired the sub comrsctors
2. 1 am a sole proprietor or panty- listed on the attached sheet t 7. deling
ship and have no employees Thee have g. lition
working for me in any capacity. workers'comp. insurance.
IN*workers'comp. insurance 5. We arc a corporation and its 9. °g addition
squired) 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,j1(4),and we have no 12.0 Roofrepaira
insurance required.) t :mploycca.(N0 workers' 13.❑Other
comp, insurance required.)
��n+PPlieua:dr eRacYa low!rt ram also an w We•gesso ts:Iw Ywwiea Ihrir wwaas•almpp•Wiw pulWy ioGwwlalius
Itwiwnamla who supnil this atadwe indkoine espy an;doiyt an wok one thin Net gut"eonln"M WAM.UAnis a o arRdevis Wielding"wk.
�Cuwrxlura that chak Otis box aunt antid"d an addtlianal MINI Anwuy ate name of the and their wurkm*cTMM•iakY udbmmnue.
I am on employer that b provldlnir workers'compertradoa insurance for my employees Bdow Is the t>v/lay and Job s'lb _
Insurance Company Name:
Policy 4 or Sail ins. Lic.is: _ ._ . ._. Expiration Date:
Job Site Address: City,StutuZip:
Attack 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.IGL c. 152 can lead to the imposition of criminal penalties ofa
tine up tin 51,500.00 and/or one-year unpriwmmncnt,as well as civil petmitiia in the form of a STOP WORK ORDER;rut a fine -�
of up in i250.00 a day against the violator. He advised that a copy of this slawaicnt may be flit-warded to the 011ice of
InYCalhal101V al the DIA for inlurance cOv Cra.L' veflFeation.
I do hereby renify mnder rhar pains and penuliks of perjary rent the Informat/on provided above is frame mild correcit
1i•ra ,r• // O 7
,� Date
PM n:a p:
Faxeonly. Abe as write is this area,to he completedby city or flown offlelid
Permit/l.leenseAutbority (circle one):ofIlealth 2. Quilding Mpartmcot J. Citylfowa Clerk 4. Electrical Inspector 5. Plumbing Inspector
Conitact Person: Phone p:
i
Information and. Instructions
Aiassachusctts General Laws chapter 152 requires all employers to prov in ide
workers' coon ensaati tion for heircanal CMPIOYCCL t of hire.
Pursuant to this statute,an esyfoYee is defined=`...every Person
express or implied,osat or written"
aasoeisdM corporation or other Argil entity,of any two tr tmoa
An erpfoyw is defined r"an iadividtsai.partnership. or the
Of the foregoing engaged in a joint enterprise.erns including the legal representatives Iinti to a deceased employer,
association or other legal entity,emploYina employees However the
receiver or worms of m individual,parmershnp. and wbo resides therein.or the occupant of do
owner of a dwelhSg base having ant there than three
or re work on such dwelling house
dwelling house of another who emPloys Persons to do maintenance,c.teawc°°° be deemed m be an employer.
of on the grounds or building appurtenant thereto shall am because of such employment
(.1GL chapter 15Z ¢25C(6)also stares that"every state or beat lkatssint ageaey dhaa withheld the issaaaet or
renewal of a license or permit to operate a business or to eotastrad buildings Is the cemmoaweaNh far Say
appaeass wbe has net prodaeed accept"evidence of aompUanoe with the insurance coverage required"
Awl
itical 06div'sions
.Additionally.MGL chapter 153. 2 of bloc w r the eomcmnwble h nor anyevidence�c its pliance with insurance
enter into any contract for the pert bloc wort until acceptable
requirement;of this chapter have been presented to the contracting authority.*
Apptieamt
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and if
necessary.supply subcontractor(s)name(+),address(es)and Phoan number(s)along with their certificate(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 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 line.
City or Town 0MISIS
Please he sure that the affidavit is complete and'piititid 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[
/'lease be sure to pill in the pormit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple Psrmit/license 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
townl•"A copy of the affidavit that bas been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. Anew affidavit must be filled out glob
year. Where a home owner or citun is obtaining a license Or permit not related to any business or commercial venture
t i.e.a dog license or permit to bum leaves 616)said person is NOT requited to complete this affidavit.
I'hc Ofticc of Invasti.ations would Cue to thank you in advance for your cooperation and should you have any questions.
plcuse du not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Depattment of Indusaial Accidents
Offln of[avosdpdoas
600 washingoon Strut
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
2cvi.cd 5-26-05 www.mam.gov/dia
-40
CITY OF SALEM
PUBLIC PROPRERTY
DEPART%IENT
al�u• t3P /Irv::Js►i.7utT•iura.ltavctt�wI&Ab%v
tt•:YOL�f�9M�f•►te 9�iJ�0+MN
I
construction Debris Disposal Affidavit
(requital not an damolldca and smovadoot wat)
in uconhum with the sixth edition of dw stag Suildh*Cods.790 CMA soction It 1.5
Debris,oad this provisions o(M. GL a 44 S etc
awlaq romb t _ _ is issued with dw coadidos fist the ddaris raa d&S f m
this wort shall be disposed olio a properly Ileum"waste disposal facility as defined try.%iGL a
1 t l. : 150A.
The debris will be transported by:
— taoaw al ed
rho&-bds will be disposed *fin :
Wants%of rultay)
�J.a�'fa of rax:Lty) .
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oFQPPDTMENT
MWIS arm
130 Wry S-WO •sMAMk HA0A0&A TR 01W0
AlPI1CATION FOR TBZ RUAHL RZNOVw1'iA1�L tn>vcrQ>trrrrnnr
DZ,HOLTTION.OR CAANGZ Of U3Z OR gnsM:
1.4 SITE INFORMATION
�ocatioa Nance r.��
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F%WwIV Ia bcded Ins;Cormnalien Aria YM Hldoda ols w YIN �
F
ERSHIP INFORMATIONr of La"
TOM~.
&a COMPLETE THIS SECTION FOR WORK IN ILIXNGS ONLY
Addition t.xlstlrtp 2
RerAwadorl v1 Number of Stories Rarw tad
Change h Use New
Demo0don t.xistip
Approximate yaw of Area per Roar(of) Renovated
constn,cdon or renovation
of existup buildup New
Rad Description of Proposed Work. U Su..(-�0.0 R e)cis--i r,5 r,
If-ccv- ar-\4 B(,e Skooe .
--- - - ---Mail Permit to: - -�
1ARtat is d►a awmt
use of the Bum?
Materiel at Sutklkg7 E dw@Wi&how mart"mils?
VtN ttta f�Conbm b I.aMR
�.0 5 Asbesbs9
Ardlimd's Name
AddrMs and Phone
Medminies Name l
/v Address and Moan Uoarw d /� HIC Rapiairadon
Conatn+�
EslbnMed Coat at Project f ( D - �FN CACIAMI bn
PerrNt Fee f
. EVdM9IAd Coat X$741000 Redd&"
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-- - -- - - Es*nalad Cast X f41/f1009 C mwcl* ---An Addltlond fti.00 Is added as an
Adw&bt vdvs drarpe.
Make cum that all flelds are Properly and legibly w M n to avoid delays in processing.
The wtdersipned does hereby apply for a Sulidinp permit to buiid to the above stated
apeodicOWdL Signed under penalty at psrj " x
Date
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