107 LINDEN ST - BUILDING INSPECTION CITY OF SALEM
• �' PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required fur all demolition and renovation work) .
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of N1GL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as define by 'v1GL c
111. S 150A.
The debris will be transported by:
7Y-oPA
t name of hauler)
I'he "Icbris will be disposed of in
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CITY OF SALEM
a PUBLIC PROPRERTY
DEPARTM
ENT
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Ki\1111 KLFY DRNC01 L
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TeL: 978-74 9595 • Fex: 978-730-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
I
Narne i Busincss,organization/Individual): KIC__f_ L0,+ L4
I
Address: 6 5- llrL lek v s�l ill i:_U<f
City/State/Zip: - e !Phone (7
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 tun a general contractor and I 6. ❑ New construction
r have hired the sub-contractors
nployees(full and/or part-time). 7. ❑ Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
i ship and have tw employees
These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
5. ❑ We ore a corporation and its
p[No workers' comp. insurance 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of per MGL 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work g exem tion P P
4 myself. [No-workers' comp. a 152, §1(4), and we have no 12.❑ Roof repairs
j insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box HI must also till out the section below showing their workers'compensation policy information.
t Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Nuute:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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
in the form of a STOP WORK ORDER and a fine
risonment, as well as civilpenalties
line a to S 1,50Q(l0 and/or one-year imp
P
that a co of this statement may be forwarded to the Office of
Of up to 52�0.00 a day against the violator. Be advisedcopy y
Investigations of the DIA for insurance coverage verification.
/do herebycerti and•r tl tuns u pena lies nfperjury that the information provided above is true and correct
fY
Si' /7
Si,manlre:
/ � Date: > Z2 Zt-1-6
Phone,n A?W �- 5? 3 — l/2-
Official use only. Do not write in this area, to he completed by city or town official.
Citv or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
PUr5nam to this statute, an employee is defined as"...awry person in the service of another under any contract c jhire,
express or implied, oral or written."
:\n employer is defined as"an individual, partnership, association, 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 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 thin 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."
.%IGL 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 till 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 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 renamed 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 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 permit/license 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
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 filled 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 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 tax 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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
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` OARD OF BUILDING REGULATIONS
. r ,ONSTRUCTION SUPERVISOR
:umber CS G3437
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERNIIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
"
IMPORTANT:: A tern on this page
Applicants must complete all t
SITE INFORMATION
Location Name Buil ing
Property Address 1j67 L J n j�
Map# 2-- i/ 461efA16 pp-0PEA fIDaklSS
7
Located in: Conservation Area Y/N Historic district Y/N
i
Use Groups
(check one)
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel RI _
it (check one) Assembly (churches) A I _
New Building_ Assembly (nightclubs etc) A2
Addition Assembly(restaurants, recreation) A3_
Alteration Business B_
Repair/Replacement Educational E
Demolition_ Factory (moderate hazard) FI
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard 11
s r Building Institutional (residential care) It _
Accessory y g_ 12
describe Institutional (incapacitated)
Other( ) —
Institutional (restrained) 13
Mercantile
M _
Storage (moderate hazard) S1
Storage (low hazard) S2_
ram'
OWNERSHIP INFORMATION(Please hype or Print Clearly)
OWNE
R
Name �e®� N u e#1
Address
Telephone 7y/ - 760 - %6 617 - s 7/- 9 75 z
DESCRIP" IOt OF WORK TO BE PF.RFOR�Ih:D / I LL
�Rc.[p PP hart Lin `5 (A a�G T C PC r' r z-�I4- r/�
_Lnv I ae� / I -InQC �iAT1. Y :�.�YAV� '�)( XJ�I�w� ICe _ I IP L
f ( I l_�Ch b�✓lh C �1_1 A,Lj 11�0"YS �a mile T2
ESTIMATED CONSTRUCTION COST g 0 OHO J� f
/ D� L
CONTRACTOR INFORMATION
Name
Address L e Ur Ir
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCIIITLU17ENGINEER INFORDIA'1'ION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $7/$1,000 + $5.00= 7 S
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge under the penalties of perjury ��
Signed � y
)m ,
Date
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