87 LEACH ST - BUILDING INSPECTION (3) Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this suture, an rmpfoyee is defined as"...every person in the service of another under any contract of hia ' '
express or implied,oral or written."
An empipi,or is defined as"an individual.partnership•association.corporation or other legal entity,or any two"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,pa mership,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 work on 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
applcant 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 contiam 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-contractors)name(s),address(os)and phone 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 an requited 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 line.
City or Town 0Mcl2b
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.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permiulicense 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
I 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 tilled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Off ice 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
O®ee of lnvestlgatlons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mam.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Sri\Iflr R[F.Y l)RISt:ULL
M. Ayot IY'WAstdwioNSTREhT•SAIF-1t,M.tssACInat:i-rs0197;
're.1:978-743.9595 4 FAX:978.7404946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumbers
Aorilicant Information Please Print Leeibly
Nit=(Business/organi:atioNlndiv,dual): CLI_�LL1r4 e yN0f 41t /
Address: ? IJ l i'I-l�I
City/Stwc/zip,,�J�//a/"1 f Phonell: L9 V- 7S'f- 2�9 ,0
Ara you an employer?Check the appropriate box: Type of project(required):
1.Q 1 am a employer with 4. Q 1 am it general contractor and 1 6. new construction
employees(full and/or part-time).• have hired the sub-contractors
23,I am a sole proprietor or partner- listed on the attached sheet. % 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
working for me in any capacity, workers' comp. insurance. q, Q Building addition
f No workers'comp. insurance 5. Q We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have cxercirtxl their
3.Q I am a homeowner doing all work right of exemption per MGL I LQ 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.❑Other
comp. insurance required.]
-Any upplicaa that checks box rl must also fill otu the wchm tkluw showing their workea r eumpanudiwt policy infumuuiwa
'110mWrwnan who submll this affidavit indicating they ate doing all watt and then hire outside eontrnuon main submit a new amdavil in,liaaina utch.
C.rttrxwn this;bast[this box tnttrt attached m additional short showing the namo of the sub-comractos and their wurl an'comp.policy information.
I ayn an employer that Is providing workers'compensation hisarance for rrry employees Below is the policy and job site
information.
insurance Company Name:
Policy it or Sclf-ins. Lie. il: _ Expiration Date:
Job Site Address: CityrSlate/2ip:
attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to wcurc coverage as required under Section 25A of.%,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up(4)S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy ul'this slatcmcnt may be forwarded to the Office of
fug cangatiuns ul'du DIA for insurance coverage vcritication.
I da hereby Terrify rider die pains rd penahiev ofperjary that the information provided
/above is true and correct
Ph,m s 7: I �0 - /Lts- 2- 2- o L? (r) Y�y /
tJJfcial use only. Do not write in this area,to be completed by city or town of iciaL
City or Tnssn: _ Permit/License A
Issuing Authurily (circle ouc):
I. Board of health 2. Building Department 3. Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: — Phone M•
What is the curre
nt use
of the Building?
MSaaterial of Building? / LL if dwelling.how many units?
win the Building Conform to Law? '� Ef Asbestos?
Architeas Name
Address and Phone t )
Mechanic's Name
Address and Phone
Consbuction Supervisors license# 06 ZZ3 L/ HIC Registration#
Estimated ed Oo 0, l� Permit Fee Calculation
Permit Fee Estimated Cost X$71$1000 Residential
_--- _ -_- -- - - Estimated Cost X$11/$1000 Commercial
--------
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications.
under nary of perjury X
Signed Pe
*Date
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�ALE� --
'' PUBLIC PROPERTY
DEPARTbIF.►�iT
KI%GIFaLEY DRISCO"
MAW* 120 WAUUNGNW Sh1EU•1UW4YASSAC1WS07S01970 I'
1ta:91104i959S♦FAx:97}740 9H*
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR K FOR ANY FMSTINGI
STRUCTURE OR BUMDV(G
1.0 SITE INFORMATION W
Location Name: Building:
Property Address.-----
-- - -
Property[a located in a;Conservatlon Are@ Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: /� ,T17 G� ✓
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
ro4c-Cefr
ef Description of Proposed Work: e o O ✓q-T d
Z _311` j1tiS l?` IlJSJ /�/1h �iJ �S
--- ---Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTN4ENT
..T,:i:NI rAt' 19:0I A.
%L%Iolt 12C W.%.i11tKt::0,%S RUT 4 S.aua.%f.%Siu::u a i l5 MIC
TEt:VM745-')M •F- 9711.74G9646
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5
Debris, u1d the provisions of MGL c 40.S 54-,
Building Permit 0 _ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l It.S 1.50A.
The debris will be transported by:
CI Y n'0 1
(name of hauler)
me Jcbris will be disposed of in :