80 MARLBOROUGH RD - BUILDING INSPECTION _ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Hereto 12C Wwanw`raarSner•Sa te�t,ltnasaCt a.:Q7•ts O197$
'fat.97&745.9595 •FAX:9M?40.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/PMmben
Applicant Information / n Please Print Legibly
- Name tlwv�•ssmraaninriwvlm4vuluan:/ �- y n!' r'1 ( 9� 9 Arl o, 1
Addrm
city/staccJzip: ��1�,,✓+ //f7 - I'!> a /�7 - �� ' 60
Are you an employsr7 Cheek the appropriate boa: IF
of project(ratialrad):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor cad INew construction
eynpluyces(full and/or p:wtinu).• have hired the sub-eoruncton
2 1 am a sold proprietor or partner. listed on the attached sheet 1 Remodeling
ship and have no omploycwt Them sub-eonnscwn have V.
Demolition
working for me in any capacity. workero'comp. insurance. 8uildiag addition
(No workers•carp. Insurance 5. ❑ We am a corporation and its . Eu"aii
required) ofeero have exerciacd their repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOIL 1 I.,Q_,,�PI �ing repairs or additions
myself.(No workers'comp. e. 152.41(4).and we have no 12,LTlt wfrt:pairo
insurance required.)t employees. LNG Workers' 13.Q Other
comp. insurance required.]
Ally.pplisaot TheeMeka eon lot mapa4w fin w the seen"txbw•aow as their wuhtaa'Wmpp ride pu16.y ie6xwW iap
tiw ownwa who uJpnd lass affidavit indicating May ate daino an weak and dice hire awaida enaraemn nuwf•uhnit a,raw attldavit indicrina.wh.
:C. ra con this crock this bat tap uuelwd m addidemu Am showing the nano or ere A&Muracion and Their wurkam'spy.policy milism rk a.
/um un employer that Is providing workers'competssadon hunrance for my emp/ayes
.. Below is thepuly andosue,infttrmuta: � e —_ . _ leJ _
._
Insiurance Company Name:
Policy A ur Saif ice.Lic. 0: Etpirruon Date:
lob Site Address: CitytStaluZip:
Attach a copy of the workers•compensation pellcy declaralloa Page(showing the policy number and expiration(ate}
Failure w secure coverage as required under Section 25A ot•.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisoninent,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to 5250.00 a Jay against ilia violator. lie advised that a copy of this statement may be tbrwarded to the Otlice jr
Ice.,hgjimns of the DIA for insurance covcra.c vcriffcation.
/Ju hereby c�enAify�,tdar the pains and tee s tirperJary thw the i eforssallon provided ubove is true and correce
V�
( C ii�, O V p — /00 f S
t)/flc/a/use on/y. /b not wdp/a f"r area,to bs eump/ete/by Illy or Iowa ojJlchd
cityor'rown: __ YermitJlJecnseK
Issuing Authority (circle one): —
1. 11oard of Ilealth I. Building 0cpartmcut J. City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Pcrsoa: _ Phone p
Information and Instructions-
. compensation _ �
lvlassachusctts Gencral Laws chapter 132 requites•all employe ov s�erwor vice of another under any their a of hire,
Pursuant to this statute,an rstpfeyee is defined as'...every person
express or imp►ied,oral or written,"
asometiM cpporaties or other legal emtitye or any two a more
.ka ewdoyer is defined as-m individual,partnership. le representatives of a deceased employer.or the
Of the foregoing engaged in a joint enterprise,and including nil eP employees. However the
association or other legal entity.employing
receiver or trustee of an iudividng of more
shaP. apartumue and who resides therein,or the occupant of dw
owner of a dwelling bcuss having not more than three maintenance.
aintenan
dwelling house of another who employs persons m do ^"•�""•"`e� strc'cc°n or repair wont on such dwelling house
or on the grounds or budding'appurtemant thxem shall act because employment be deemed to be an employe.
that•Ov are"or focal lieentsbag agency shad withheld the isstunee or
stares Mt
AtGL chapter 132e§tor pe also i•the cemmoawealth fir say
renewal of s grew or permts to operate a business or a eottatruet btsildings���coverage required."
sus trot tread acceptable evidew of compliance shall
who P� political subdivisions
sppdeastt theof its
Additionally,MGL chapter tope blicwork until° ep�a evidence of compliance with the insurance
enter into any contract for the performance
authority."
requirements of this chapter have been presented to the convecting
Applicants
Please fill out the workers' compensation affidavit completely.by checkrttg the boxes that apply theft certificate(s)rt iffca your situation and if
necessary.wpPly+�onuac�s)natne(s).addm-*cs)and Phone nwnber(s)slang wig► s)a rhea the
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employ
insurance red carry workers'compensation insurance. If an LLC or LLP does have
members or Partners,are net required to
employees.a policy is required. Be advised that this affidavit maybe submitted tnd o the Ikparonent of Industrial
Accidents for confirmation of insurance coverage. Also M surest l° is being the uestedevnot the Department of d
be returned to the city or town that the application for the permitget
Industrial Accidents. Should you have any questions regarding the law or if you are required co obtain a workers'
compensation Policy,pleats call the Department at the number Hated below. Self-insured companies should enter their
,elf-insurance license number on the line.
City or Town Olflelshl
Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space atthe bottom_ •. w
of the affidavit far you to fill out in the event the Office of Investigations has to contact you regarding the applicant,
lalease be sure to fill in the pormit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple Pernit/licenae 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
affidavit that has been officially stamped or marked by the city or town may be provided to the
town)."A copy of the affidavffidavit is a file for future permits or licenses. A new affidavit must be filled out cub
applicant as proof that a fid a is obtaining a license or permit not related to any business d commercial venture
year. Where a home Owner a citizen
t i.e.a dug license or permit to barn leaves etc.)said person is NOT required to complete this affidavit.
I'ha Off ice of Investigations would ac to thank you in advance fur your cooperation and should you have any questions,
pleuse du not hesitate to give us •a call.
The Department's address.telephone and fax number.
The Commonwealth of Massachtuetts
Department of Industrial Accidents
OAI"of Iavesdpdome
600 Washin6toll Sweet
Boston, MA 02111
Tel. p 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
2evised 5-26-03 WVYW,maSa.gOv/tlla
CrTY of SALEm
-PUBLIC PROPRERTY
DEPARTMENT
�.Var tll a� '�a9t
]la.• lJ."RANT:Jl►S1tLT�i�lF11.1L�VL�t:iN�t�1a::4. "
Construcdon Debris Disposstt Affidavit
(rNuimd for all denalidam and tenor adon worlt)
In accortlmm with dw sixdl edition otdw State Building Cods6 730 CNII suction 111.5
Delxia,aad dw provisions a(M. CL c 40.S A.
9uilditts pam&0 _ _ is iswwd with the cood Am that the debris resulting hum
this wait shall be disposed of in a properly licensed waste disposd tbcitity as dented by WIL e
l t 1.S 15OA.
The debris will be transported bye
rhedcbds will be d
is
posed of in :
t nuftr ur fxfi,ty)
e
Cl I V OF
PUBLIC PROPERTY
DEPARTMENT
ns�aa+a•+sie.►Ass��+esw
APPLICATION FOR THZ REPAIR. RRNOVATiOnt r_nMorrrrr M
DEKOLITIOPL OR CHANGE OF CSZ OR OCCUpANCv rt
, FOR Ay F]CL477At(�
aTRLiCTL�= OR BIM DING -
1.0 SITE INFORMATION '
Locaian Name: In
---
'0
Properly Y kxxsDsd N a; lbes YM tilslarlo DlsMiat YM
2.0 OWNERSHIP INFORMATION
M Owaw a1 Land , ' t r _ ,
Names
Address
$o o
Tolepho ..
zA COMPLETE THIS SECTION FOR WORK IN E7IL11LdQ 9UILDINOi ONLY
Addition Existklg
Renovedw Number of Stories Renovated
Fad2d,fD&SC#iPd0n
Use New
e year of Ana per floor (s1)n or renovation
uildingpdon of Proposed Work:
o� 7
--- —- ---Mail Petrnit b.
yy �
hat is ti1a GYrsnt use atttheOuidtnp9 L szeLbl
, . .
Material of su�trg7 Dy k diwearq.howtY unUs9
WI/tin OtAMV C*nftMIO LM? Vg MbM1Ds9
C)
Arddlaot's NOWO - —
AddteM and PAorM
Mods
Addnas and Phone
couwuckn Suparvwm uoame• HIC Rapistratlon d 1 S
EslinMad Coat d Project s / Psrmt F«Calais
P.YrA Fee ZI — Estlmswd Cost X$7/111000 Residential
--_ -- - EaMnatsd Cost X=11I:1000 Con+merdad-----
An Additional=0.00 Is added n an
AdmkristrSdve d--
Make sure that all fields an properly and Iso"vvritian to avoid delays In proeessln0.
The undarsipned does herby apply for a SuUdkV Permit to build to the above s d
bra, SWad under Pwuft Of tWjurY
2L
Data //- 7-�5 7
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