68 LEAVITT ST - BUILDING INSPECTION CITY OF SALEM
�w1 O PUBLIC PROPRERTY
<� a> DEPARTMENT
'Im":RlF.y ORI5COLL
M.vvtat 12CWA'H11% 0NSTREEToSAIEM.MAaAUH.VS..1rn01970
Tra-97111-745.9595 o FAX:9M740-9916
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
NIMe iBuaincsslOrganizationtlndiv,dual): /J�/�Vzw- �„¢� .''/0-
Address: 3
CityiStarcizip: 0/9-7J Phone #:
1 Are you an employer?Check the appropriate box: 'rYIM of project(required):
1.❑ I ant a employer with G 4. ❑ 1 am a general contractor and[
6. [3 New construction
employees(full and/or part-time).' have hired the sub-contractors
2.® 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employcex These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
lno workers'comp. insurance 5. ❑ We are a corporation and its
n:quircd.]
officers have exerciwxl their 10.❑ Electrical repair or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers'
13.❑ Other
comp. insurance required.] Y Sites
.Any applicants that checks boa 01 must also Till can the veetian below thawing heir wwkws'cumpenud"I pulivy infinnwtiorc
'Homeowners who submit this Affidavit indinding thry arc doing all work and then him outside contractors most.ubmid a new affidavit indicasing welt.
CundrxVrn thin chsslt this Isar must attached an additional throat showing the nand of the sub-comracton and their workers'comp.policy infirmmtina.
l our on employer that Ls providing workers'connpensadon Insurance for say employees. Below is the policy and job site
information.
Insurance Company Name: G/Z�'LCf O s%4l e
Policy#or SclGins. Lie.0:/W0, Z �o 7 Y0� . _ -__ Expiration Date:
Job Site Address: 1�57— C1ty1StatdZip:r974",7
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of.vIGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to 5250.00 is day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
Imcsngations ul'thc DIA for insurance covcragc verification.
/tla hereby certify under the pains and penuthiev u perjury that the information provided above is true and correct
tii :ru ore' � ✓ CEL..-Y�p Date- —� '
Phi roc iv
f)Jfcial site only. Do not write in whir area,to be completed by city or town oj]iriait
City or'rmsn: Permit/License
Issuing Authority (circle one):
1. Buird of lieaith 2. Building Department 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ Phone p:
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 emplojwr is defined as"an individual,partnership,assocramon,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 deceused 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 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."
Iv1GL 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 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),addresses)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 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 line.
City or Town Offlelals
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 pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penmitilicenae applications in any given year,need only submit one affiduvit 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 tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business orcommercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
1'hc Ot)i.:c of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OAlee of Investigatleoa
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 SALEM
PUBLIC PROPRERTY
DEPARTMENT
�L\ua t�C W.\91tu::J�S AE£T 9AL!M,ft.\S!Lu::u %Ells:19/:
Tet:9M7439M •F.%.c:978.74C 9846
Construction Debris Disposal AtTidavit
(required for all demolition acid renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CbiR section 111.5
Debris,and the provisions of M. GL 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 viGL c
I11. S 150A.
The debris will be transported by:
(dame at hauler)
fhc debris will be disposed of in
(name uY Iacllrty)
J
R- 07
EITy"OF
PUBLIC PROPERTY
- DEPARTMF1�iT
M.%GWMKV DRISC LL
�twraa 130WAMGNGRxr$Tun♦SAujKNAsucMLSk s01970
APPLICATION FOR THE REPAIR RENOVATION_ CONSTRUMON,
DE,rIOLMOM OR CHANGE OF USE OR OCCUPY CV FOR ANY EXISTING
STRUCTURZ OR HUIIADUG
o SITE INFORMATION
Location Name: is'- d' v — , , Building:
piny --------- - -- - ---- J-
Property is located In a.Coraena0on Aron YIN Historic Disbiat YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: f li , l L l iv sz
Address:
ST S,a/1�1,7
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISMI G 8UILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brie[Description of Proposed Work:
------ ---Mail Permit "M 9�f /�/
What is the current use of the Building? _l "
if dwelling.how many un
Material of Building?
wa the Building Conform to Law? pf Asbestos? �U
Architeds Name
Address and Phone
Mee woes Name
� Si `ivvP.l✓ �- di9-s-3
Address and Phone z
Construction Supervisors License 0 HIC Registration 0
Esftated Cost of Project i / Per" Cakxibrtlon
Permit Fee i_� Estimated Cost X$7/$1000 Residential
EyWnsted Cost $41/i1000 foenrnerclal---------_ _.
An Additional$5.00 Is added a$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. Signed under penalty of perjury x zz; —a"" ��
ific
Date o
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