25C MARION RD - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
a MUR1EY URrAXICL
M. Ay s 12C V A%mNGroNsrawr a SAizu.MAgActn.�:rno197C
'rta:971.745-9595 a FAX:9M740-9M
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Leeibly
Name iaustiweswV)rganizatiordindividuul): 0✓,0� 4J. l ' A e r r-a -
Address:
CityiStare/Zip:_,S .Ie , h Ci/!
Are you to employer?Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. Q I am a general contractor and 1 6. Q New construction
employees(full and/or part-time)., have hired the sub-contractors
2.�I]am a sole proprieteir or partner- listed on the attached sheet. 1 7. Q Remodeling
ship and have no employees Then sub-commema have 8. Q Demolition
working for me in any capacity. workers'comp. insurance. 9. Q Building addition
(too workers'comp. insurance 5. Q We arc a corporation and its !0. Electrical
requir d) officers have exercised their ❑ repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152,§I(4),and we have no 12.Q Roof repaint
insurance required.) t :mployccs.[No workers' 13.Q Other
comp. insurance required.]
*Any upplicaot that chwks box 01 mum also till out the mclien W-low drawing chair wakens'CarltpMYttinn poticy iof airegiun.
' I I,.xtvnwnwa who submit this affidavit indicating they ate doing all murk and then hits outside eantroeron mutt•uhrnii a now attldavii indienting auk.
•Cnniraua n that cheek this box must aeaehd cot additiond JhW flowing Me new orate Alh4ontrxiera and their wurken'tamp.policy informative,
i am an employer that Is providing workers'compensadon huurance for my employees: Below is the panty and jab site
in/areturian.
insurance Company Name:
Policy q or Self-ins. Lic.N: _... _._ Expiration Date:
Job Site Address: CitylslatGZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to wcum coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisornnent,as well us civil pcnallics in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the 011ice of
Divcsngalions ul'Lhc DIA for insurance covcra,c verification.
l du hereby terrify under the erns aiodypen(uldess ujperjury that Cite iaformWion provided above is true and correct
tii•:rnurc: -- -- -�—�_¢ _sss ,!" __ Dam.
Phr�t:c is 7 � • S
I0,%-;al use only, DO ear wrist in this area,to be Completed by City or town o/j7t'i d
Ciry or 'rown: Permit/Llcense 0
Issuing Authority(circle one): --
1. Iloard of Ileallh 2. Building Department 3.Ciglrotvn Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Coutaet Person.:--._ . Phone p:
i
Information and Instructions
btaisachus
u+etts General Caws chapter 152 requires all employee to provide workers' compensation for their empbyoe&
pursuant to this statute,an emPloyee is defined as".•.every person in the service of another under any contract of hire.
eapress or implied.oral or written."
Art employer is defined Y"an ittdiividuaL partnership.association,corporation or other legal entity,or any two or more
of the torcgoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
recaiver or trustee of m individual.partnership.association or other legal entity,employing employees. However the
owner of a dwelling house having not more than dam apart n rots and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work oa 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, ¢25CM also states that"every state or local licensing agency shin withhold the issuance or
renewal of a license or peraslt to operate a business or to construct buildings In the commonwealth for may
applicant wbo has not produced acceptable evidence of wmptlanm with the insurance coverage required."
"Nei
visions"I
.additionally.MGL chapter 152, fo�gmance of states
c work until acceptaber the eevidence of co pliance wy of its political ith the nssurance
enter into any contract for the per P
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),address(ea)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to catty 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. Sclf-insured companies should enter their
self-insurance license number on the a ro 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 till in the perrnitllicense number which will be used as a reference number. In addition,an applicant
that must subinit multiple permitllicease 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.
I'hc 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
Ohl"of Iavestiptleas
600 Washington Street
Boston, MA 02111
Tel. Al 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
?cviscJ 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..vim MI ntti• R�a`I1
T11.~45 W FAM WIJ4t:"
Construction Debris Disposai Aitidavit
(required car all demolition and ratovatiat work)
In accordancc with the sixth editim oohs Stage Building Code,7S0 CNIR section l t I-S
Debris.and the Provisions oPMtGL c 40.S SIC
Bttildin{Permit N _ is issued with the condition that the debris resulting Atom
this work shalt be disposed of in a property licensed waste disposal facility as defined by%lGL c
I l L. S 110A.
The debris will be tnutsported by:
IIIirOf of Itiula�
fhc Jcbris will be disposed ofin :
in:.rne of ia.dtty)
.its
i
Y Emt-o�
PUBLIC PROPERTY
DEPARTMENT '
%Gran 13D Wnsmrwls�+a'nesi•S�uty sars01970
1ti;97F7�b.9Sy•Fps 9'7F.7g9W
APPLICATION FOR THE REPAIR. RENOYAn-ON_ CONSTRUCTION,
DEHOLMO& _ R CHANGE OF USE OR OCCUPANCY_ FOR sNSAC
STRUCTURE OR OR BUELD�� - -
Y =
1A arm INFORMATION
Location Name: Building:
ProWnY Address:------ -- -- — -- --- --- -----
25- C M � ►2ro)u 12c3 - -
�6 ems, A ofS � t�
Property Is located in s:Conservation Are YIN Hiskut District Y/N
2.0 OWNERSHIP INFORMATION
11 Owner of Land _
Name: M c► r c i a ,A cl 1 o w
Address: ZJ- C Mar, o v, 128
01930
Tom.
3.000MPLETE THIS SECTION FOR WORK IN E]IISIWG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
--- -- ---Mail Permit t0: o e eu,^e u,c /-B pc( 10-7
use Of the Building? t L C c p i -
,! Is ltne etarent 1 Material of Building? C�7do� 'u-» dwefling.how many unto? -___
will the Building Confom to Law? Y`S Asbestos? hl /A
N
Atdws Cs Name
Address and Pion N/A t
Meehanies Noma
Address and Phone La �� ��l M`1 dr 9 20 �} ► 'Z
Construction SupWvisos Ucwa d / R.2 $ to HIC Registration d
Estimated Cat of Project: 5• o a O Permit Fes CsWuMdon
Permit Fee S �O �� Estimaied Cad X$71$1000 Residentkd
Estimated Catx$11/$1008 C;onw rcia4--- -- - . .
An Addtional $0.00 Is added as an
Administrative CPMV .
Make sure that all fields are Property and legibly wrinem to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specftallorm Signed under penalty of perjury
�I
3
v � 0
c• .
06
s.- A _ -