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2A LINDEN ST - BUILDING INSPECTION AW cab NIL JON& M havnA►hoard ti 1►M_�.Ns � �.tL"""a *da-:= a r poop*toard . ;. Mp�rryllMd YM.�.N°� 8UMAWpgrmr APPLIMM POI (Cllda MAlldlriNr app�t) �� P IMP, our LMLr a ooYw.Mf To,%Vm aura w PrA=ssm TO THE V&pWiOR OF M Dl4rW- mo �y 1ppm fora P� 10 ma aooadinp 10 to 1oloiwirp owners Hrrna �i 7 Adam jk Phone ow-ft a'a Hann l A*m s Phone . NNW Ti IA& 11mr..S a Phone �i 6 V"asoPmpmdkdd, Ir'► wwr a ara10 I/J o o r•dwMUr), hD�N wrw boo9—r 3 J wr w�anrwwr,rrrr �S � o — � wrwa aor N A Me � U46 x aAppi�Z UMMTM PiN&TM of PELUK DUOWnOa OF W Mc To K DONE Elm -77t- 7 MAIL PE#MMT Z Iy D J�} S 7r wn e ��TO APPLICATON FOR AO LOCATION err c�rrEc . 77 l y/0 2e 2 , ,> OF eu� os e The Commonwealth of Massachusetts Department of Industrial Accidents Offte a of Investigations k�7—MM=l 9 600 Washington Street Boston,MA 02111 lwj www.mass gow&N Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbele A licant Information Please Print Lee'bl Name (ansiness//rorpmzaeo/n/I�ndividual): J-_ (r)14N- _6L� Address: Lo 5 ( �')�{9�C�N 6 � Vl t City/statemp: 11 0 0` ' Phone# 7 �1 3 Z2 Are you an employer?Chect thrapproprlate bore' 1.❑ I am a employer with 4. ❑'I am a general contractor and I Type of Project(required): 6. ❑N nstntction 90ptoyees(tun and/or part-time).• have loved the sub-contractors 2.Q I am a sole proprietor or partner- listed on the attached sheet t 7• Remodeling ship and have no employees These sub-contractors have 8. ©demolition working:for me in any capacity, worker$' comp. insuranca 9. Q Building addition [No workers'comp.insurance I. ❑ We are a corpor2lron and its' ]0.0 Electrical airs or additions regnind).. officers have eiie�cised their 3.❑ I am a hotneownm.doing all work right of exemption per MGL 11.0 Plumbing repairs or addition myself (No workerti'.comp. c. 152,§iM,and wehavew .12.0 Roofrepai s insurance required;I t. employes [N[o workers' comp.insurance rtquired.1 13.❑ Other *Any applicant that checks lox#1 a"also 5A out the section below ehowma tls+c.,wodcm'wtnpensahon policy mfolmetioa•. t Homeownm who eub®t thia`etLdavit indicating they we doing all work and then lice o eontiaetos nina submit a new affdevit indicating such utside =Contracwts that cLak this box`tnna etached ec Witiond AM showing the bfthasubwptiiicoora and their workers' cP•policy intosmetioa I am an employer that is providing workers'compenaadon Insurance jornay einp/oyees information Below it the poUry andjob sloe Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/StatdZip: Attach 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 aid/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 her cerd ands pains and ajperJury that the injonnadon provided above 6 true and corriect. Si D 2 — / 7 in #: O,alcial ase onl!a Do nog write in this arcs,to be completed by dry or town offletai. City or Town: Permt/License 0- Issuing Authority(circle one): 1.Board of Heath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General laws chapter 152 requires all employers to providese vice 4#a' compensation a for their employees Pursuant to this statute, an employee is defined as"...every Person in the service of§another under suY contract of hire, . express or implied,oral or writtea" An employe►is defined as"an individual,partnership,arsocation,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including tht legalrepresmtatives o€a deceased 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 or the occupant of the' than three apartments and who resides therein, 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 shan 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 shah 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 insuraace coverage regdred chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions Shan of public work until acceptable evidence of compliance with the in enter into say contract for the performance Sitranee Additionally,MGL ter have been presented to the councting authority." requirements of this chap Applicants ply i compensation affidavit completely,by checking the boxes that apn yotrr situation and,if Please fill out the workers' . Of necessary,sopply sub e°ntract°>(s)name(s),address(es)and phone number(s)along )with n'0 employees s other than the insurance. Limited liability Companies(LLC)or Limited Liability.Partnerships(LLP) members or parmers, are not requited to carry workers' compensation insurance: If an LLC or LLP does have employee,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also he,sure to sigh and date the affidavit. The affidavit should be returned to the city or town that the application for the permit licensew or d beingyou requested,to of 111c D PWworkers' t of Industrial Accidents, Should you have any questions regarding lease can the Department at the number#sled below. Self-insured companies should enter their compensation policy:p self-insurance license mnnberoa the to tins 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. as a reference munber. In addition,an applicant Please be sure to fin la the permit/license number•which will be usven year,need only submit on affidavit indicating current that must submit multiple permit(license applications in any given y policy information(if necessary).and Address"the applicant should write"all kmcatim in,under"Job Site Add (city or town)."A copy.of the affidavit that has'been officially stamped or marked or town m be Provided to then ked by the applicant as proof that a valid affidavit is on file for fixture permits or licenses. A new affidavit moat be filled out each btaining a license or permit of related to any business or commercial venture year.Where a home owner or atiaen is o . (i.e. a dog license or permit to bum 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 of hesitate to give tea a can. 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-NIASSAFE Fax#617-727-7749 Revised 5-26.05 www.mws.gov/dia CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Deuartment Debris Distwsal 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 FacilityYLLEM /kA V Sig a e of Applicant L / 4— v6 Date