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JN&Pj=M POW TOA.P.FJW BEING GRANTED
CITY OF_SALEM
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WALI)m PERMIT APPLICATION FOR'
Pem►tt to:
(Circle whichever apply) Roof Instal Skft Construct Deck. Shed, Pool,
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PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID NUYS W PROCESSWG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the fdW*1ing
specificatiom
Owners Name ( �aVLCS l ,
Address & Phone 20 L i V�. �S f ?�—ZP3 —glop
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Architect's Name
Address & Phone I I
Mechanics Name (:5-kC kaj
Address & Phone 20 t-"K I1'� ��^F� C) f
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Signature of Applicant
SW= UNDER THE PENALTY
OF PWWURY
DESCRIPTION OF WORK TO BE DONE
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
0
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal 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
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dle
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elep idease pal Legibly
mbers
Applicant Information
Name �nOa��vkw:N
Address: Z fl L I 4S F-�p J
City/State/Zi done
p:
r2.0
u an employer?Check the appropriate box: Type of Project(required):
4. ❑ I am a general contractor and I 6. New construction
ama�P�Ye+with • have hfred the sub rnntrac0orsmployees(full and/or part trot~). on the attached sheet t 7 cling
am a sole proprietor or partner- listed These sub contractors have8. ❑ Demolition
hip and Lave o employees workers' comp. insurance. 9. ❑ BuMing;addition
orking for me in any cap Y ,�, _-/.
[No workers' comp. insurance 5• ❑ We are a corporation nth its 10.1� mca1 repairs or additions
officers have exercised their
required.] I I.E.Pl ingrepairs or additions3.❑ I am a homeowner doing all work right of exemption Per MGL
c. 152,§1(4),and we have no12.❑ Roof repairs
myself. [No workers' comp. bees. o workers' i\In�. IGi G�tyh, �i
insurance rhea']t cow insurance required.]. 13 10 O�er_5 _—
• checks box N1 must also fill out the section below showing their wotkm'canVtcmtion Policy ID�"tioa
Any applicant that
f they ate doing an work and then bin outside connactots must subrtdt a new affidavit indicating sock
Honeownm who eulxtrit this affidavit indicatbtg
the name of the sub-=Uectm and then wotkm'cony.policy information.
tCoubusu s that check this box must attached an additional abed slowing _
1 am on employer that is providing workers'compensation Insurance for my employees. Below Is the poUmy and fob slie
Information. `�
eali
Insurance Company Name: `� (/V j -� �V •
Policy#or Self-ins.Lia #: �z U �'j�q3���7 �.. I �� Expiration Date:
q to O C�
Job Site Address:
j LelMd 1, Citylstatc7ip:�
Attach a copy of the workers' compensation policy declaration page(showing the poUcy number and expiration date).
Famil=to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ee the pains and peeabies of pedwY that the lnformadon provided b and correcR
p (/� D : //'
Phone#:
O, kid use onus Do not wrke in thin area,to be completed by city or town official
City or Town: Perinkluceme#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
1111V1111AbiVll Nllu 111061 al\.61Vi1►7
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 him,
express or implied,oral or writtw."
an ' Partnership, n 'r
An eapooyer is defined as individual, association,corporation 0 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
rxeiva 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 aparmtents 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 consumer buildings in the commonweaMi for any
applicant who has not produced acceptable evidence of compliance with the lass ranee coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
cuter into any contract for the performance ofpublie work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicant
Please fin out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies,(LLC)or Limited Liability Partnerships(LI.P)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 Deparmunt of industrial
Accidents fororinfirmatiomof insurance coverage. Also be sure to sign and date the affldaviL The affidavit should
be rearmed to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidens. 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 time.
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 applicant
Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtittlicense applications in any given year,need only submit one affidavit indicating current
policy infortnatimi(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 fawn 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'comntircial 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 s-2ti os wow mass.gov/dia