2 LYNDE ST - BUILDING INSPECTION (6) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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'rbL-978•74S.9595 a FAX:971L740.9S4G
Workers' Compenssdoe Insurance Affidavit: Builders/Contnctors/Electridans/Plumben
Analkilnt Information Please Print Legibly
Name j9uaincuX)r 7niratioWlrAhv„W):
Address: / Z/JU
City/St2mizip: /3 11445 i'honea: y;2 -G2,1- y32�l
Are you as employer?Cheek the approprlate box:
1.❑ 1 am a employer with 4. ❑ 6 1 am a general contractor and 1 . [ of mewProject:(fit)
fthpluycea(full uvUor P ut-tine).• have hired the sub-euntractora w conigntetiaa
m
2.(71 am a sok proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no omploycea Thera wbecamumrs have g. Demolition
working for me in any capacity. workers'comp,insurance. 9
❑ Bwldtagadditicn
(No workers'camp. imunu t 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required,) office rs have exercised thew
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0! PI ing repairs or additions
myself.(No workers'wrap. C. 152,¢1(4),and we have no 12. tfipain
insurance required.l r employees.LA'o workers' 13. Other
comp. imsursnax required.)
-Any.Mhci tl the chwdts dos II marl also All ins an wum IRbw thowi0a th6t w*MW arni I DuIwY�naxwulioo..
I twawwtwn who submit that amdait indraning dwy ate doing @11 wudt and thwa bin aanida celalmana elm eubmk a yaw amdavil tnaliatling Y-h.
•CJ raaars Iho chak dw box nIW inched at adgtrtwtat deal,bowing its,nade of fins sad their wunkene•gyp•pwwy Mbana ws,
I ear as employer that l:providlnit workers'compuatudoa hisurance for ray employees aglow is the pi Zy and Job nib
iaf,WIWUI a.
Insurance Company Name: -- .- .. - --- -- -
Policy a or Self-ins. Lie. M: _ .. _- Eapirrton Date:
Job Site Address: City/Stawzlp:
Attack a capy of the workers'compensation pulley declaration page(showing the policy number and expiration date)
Failure to wcura coverage as required under Section 25A uf.MCL c. 152 can lead to the imposition of criminal penalties ofa
f nc up al 51,500.00 arttYor one-year imprisnmmcnt,.is Wcll as civil pcmltiut in the form of a STOP WORK ORDER and a fine
of up to$250.00 a Jay agairiv the violator. Ile advised that a copy of this slaWatent may be forwarded to the Office of
I ws migntunts of dic DIA :'or insurance covcra.0 I airic.ition.
I✓o hereby certify ender the pt 'as aad peaaldes u0criary that the informadom provided above is truir and correct
O/flcial use nabs lee eat write is this area,to dr catsiplered by city or town o/Jli lid
City or 'rown: - Permitil.lcense d
Iuulag Autkarity(circle one): _
I. Iluard of nealih I. Building oepart,ncnl J. Cit ffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Coolaca Person: _ _ ._ Phone q:
1
Information and Instructions
.%lassachusatu General Laws chapter 152 requites all employers to provide workers' compensation for their employees
Pursuant to this atatuts.an empf""is defined as"...every person in the service of another under any contract of hire.
eapress or implied,oral or written.'
asaotaetio&corporation err other entity.or any two a man
An e„rowyw is dslined ss iattrridthal.ItP' !o er,or the
Of the foregoing engslped in a joint enterprise.and nnClluhtng legal repmsenudves lO i deceased crap Y
association or other legal entity.employing employees However the
receiver err trusms of an individual.pasmeo rear sht a and who resides thnein.or the Occupant of tie
owner of a dwelling bows beviag rat rnen then three aparseteels
dwelling house of another who employs Persons to do maintenance,cuostrucoon of repair work on such dwelling house
or on the grounds or building appointment tberem shall not because of streb ineploymant be deemed to be an employer.
MGL chapter 132.42k(6)�o sscea that"every state or loeal Heeasiag agency sbaa wkbbeM the ksttanee or
eak to Operate a beslnas or to ceesuvet buildings In As cemmouweskb for any
applijereaavrd of a e We ass or Perpe deced acceptable wMaaes of comPgana with tie Insurance eoverags requlreA."
Additi M wM beat sat Prat
Additiomlly.MGL chapter 153,423C(7)stela"Neither the commonwealth not any of is political subdivisions shall
enter into any contract for the perfarmaws of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applksnts
Please fill out the workers compensation ensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary.a+PPIY ems)nos)'tea)and Pheine du mber(&)along with their certificates)of
Companies LC)or Limited Liability Pettnerships(LLP)with no employers other than the
insurance Limited Liability ort>�to �workers'compensation insurance. If an LLC or LLP doer have
members or pntmers.am eat required Department of Industrial
employees,a policy is required Be advised that this affidavit may be submitted to the
Accidents for confirmation of insurance coverage. Abe be sure to slgu and dote the atfldavlt The affidavit should
that the application for the permit or license is being requested,not the Department of
be rcthtmed to the city a sown
Irulustrial A"ideass. Should you have any quesdoua regarding the law or if you are required to obtain o workers'
Call the Department at the number listed below. Self-insumd companies should enter their
compensation polity.Please
.elf-insuranee license number on the lam•
City or Town O@ktals
Please he sure that the affidavit is complete and printed legibly. The Deparnnant has provided a space at the bottom.
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the p,rmitllicetsse number which will be used as a reference number. In addition,an applicant
ons in say given year,need only submit one affidavit indicating curtest
that m"t submit multiple permitilicense applicati
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
copy of the affidavit that has
town)."A 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 now affidavit must be filled out each
yew. Where a harts 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 lava es•)said parson is NOT required to complete this affidavit
fhc Outx of (nvesti6auons would like to thank you;n advance fur your cooperation and should you have any questions,
p:caae du not hesitate to give Lisa call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
DeptiRment of Industrial Accidents
` 00"of[avesidgedess
600 Washington Street
Boston,MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Zev i.ed ;-26-05 www.nim.gov/dia
C'M OF SALEM
PUBLIC PROPRERTY
DEPARTUENT
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Coustrucdon Debris Dkposat Affidavit
(requit ed Cot all damlitim and renovation work)
Ia aot:o dmw w ith (fit sh&aditio s o(dw Sets Building Cod%7W CNIR soction 111.S
Debris.and the provisions o(MdGL a 40.8 54
Building Permit fa _ is issued whit the condition that the debris rea skill floor
this wort shall be disposed o(in a propaety licensed waste disposal facility as defined by%1G.e
ttl.lis"
The debris will be transported by:
C//9l? r,4rmir
_. (Hewn of hadM
rho:kbris will be disposed of in :
y"-1 C//q/? cy;� V(
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CITY aIA1141ilvi
r .
PUBLIC PROPERTY
DEPARTMENT
MAYM 120 WA3MNGWW hnLFlir•
ULtx.MAStAa+nstll5 01970
TM-978•745-M9S •FAx,971.740.9s"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY VaSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address..
Z ti0-
Property is located in a; Conservation Area YIN Historic OWkk;t Y/N a
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Me PgWMAi
Address:
2 � tiMi? `17
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYtATtuca BUILDINGS 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
Brief Description of Proposed Work:
-- - Mail Permit to: d -
What is the current use of the Building?
Material of Building? alD CA if dwelling, how many units?
Will the Building Conform to Law? //Pq3 Asbestos? NG
Archites Name OVA/l �A% t
ct'
Address and Phone LGW.:;7 `n 13F.1r✓RL, j j
Mechanic's Name o-"W;/1
•Zi � 9 Loi�x 7? 13r-1�'tj�, 97j-G2/-S�3z�
Address and Phone
Construction Supervisors License/1 OJ O`I Z HIC Registration S
Estimated Of Project$ L6- `' Permit Fee CalcuWW
Permit Fee i LQ'00 Estimated Cost X$7/$1000 Residential
Estimated Cost X$1141000 Commercial An Additional $5.00 is added as an
Administrative charge.
5
Make sure that all fields are property 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
Date 3 �•�
b ,O
o° ) 3. o
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