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ACDRD'ib(ZO��ba) � �A DCOACOR4T N1988
CITY OF SALENt
PUBLIC PROPRERTY
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pebria.md the provisioro of NGL e 4q S SI�
8ui1.1in�Pennit A _ . ii i�aad with th�Condltios dfat the d�btis[aultins�as
chis wwk�cAsll be dispoaod of in a properly 1lcenscd wast�dispwal Pseiliry as delined by�lGL a
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UBLIC PROPRERTY
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annlicaat Informntioa Please Print Leeiplv
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A�drt�s: �a � � y�
CitylSts�clZip: o I'honeH: �� �-� " �o�( �i
,�rr yoa r�employ�r?Cheelc tAs aPProP�Ia�b��• •ryp�o�proj�����y��;
1.� I;up a empluyer wi�L 6. ��}'1 am a Yenual eoaltaetor ana t
ompiuy��x(full uuVur pui-�ime).• I18VC hlM�i II1C a11MCu11tRCtOft b' ��f'"comaruetion
?.Q 1 am a,wle propriccar or panner- tisced on die atached yhoet � 7. [�temode�in�
ahip and have no employcm T6es wbeonaacton hays S. ❑,�,/Demolidon
wohin� for me in rny c�pncity. woricen'oomy. insurnnoa 9. Ll Qi�dition
(Ko waten'comp. inwranct 3. � We an a eorporatia�and its lO.�aieal r n ot additions
nequiredj ot7[eers have cxcrcira!r6e'u �
3.� I am a haneowna Join�all waic riaht of axemption per MGL I 1. lumbing repain or uckiitio�u
myxlf.[[�o workcrs'cump. e. 152.§I(4).aad we lwvc iro 12.Q lt�wf npain
imuranee requind.J t �mpbyers.(1�'o worktrs' 13.�Other
comp. iRwran�requirCJ.j
•nn>:y�plicml tlr clwcM�Eoa II man alao flU wl lht.ectim IRbw ifluwia�t�if awrlon•ur�a�bw D"�i�y ioRrm.'ipa �
'1�wnm�r�n«s wb iu0mi�Mia oflldwu indka'a�May aR Juiy�tll work md t4o A4o owfid�ear(oc�an mru.W�ni�s owv afll�hril iiWiariny.w�.
=('murxvn�hr cksk'ha!az nuw anxhd as addi�iarl Wr1.Aowiiy We nmo of tll�abeontrapaes aad their�rwkas'ea�V•W�iry infhnnaMu�.
/um an rmpfoyrr lhat&provldJng warkirt'compenradoa Lu�rauce jor iny employtes Btlaw fs rhr pu//ry unJfob r!!i
iuj�rwudfwua
In.urancn Company Vame: . .... . . ... - -- - _
Policy Yw Snlf-ins. Lie.p: .__. _ .---- Ecpirrhon Date:
Job Sitc AdJresx: CiiyiSWlu2ip:
�tt�cA a cupy of th�worken' compcnsatlnn p�ilfey declar�pon pa�e(s6owfnR the polley numbcr and c:pir�Nun date}
I�ai lure w x:cu�e coveraea y«quircd under Sectiou?SA uf�iGL c. 132 esn lesd ro the impoai[ion of eriminsl penaltip of s
tTne up tn S 1,500.00.nJ/or ona-year impriaw�mnent,ay wcll;u civil pcnuUiut in ihe fortn of a STUP WORK ORDER and a fina
ofup m i350.00 a Jay a�in� ihe viulawr. lie advi�cd tAut a cupy ufchis siaLLuunt rtmy bn turwarJrd m the UOice uf
III\'C\�I�;lI{UtlY UI ihe DIA for in;unr.cc:ou.r�yc rerifiu�iun.
/Ju hueby r.niJy an.fai d�r pui ud r prrJury thm d�e ie/aima/Iow proriJed ubow is na�unJ rorrrce
Ci�t:rrturet - - I} • p 8
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O/J7rid�rt ua/�c /)a ear wrlie/w ib6 airs.ru b�ruap/deil by t!ry orinwa o,07e%L
Cily or Town: __ PermiNl.lecase M __. . _ _ .
ls�uln� Au16uri�r (circle onc):
!. Ifu�rJ uf Ilrrllh 2. ISuilJin� Dep•rrtmeot J.City/foNn Clerlc J. Electrical Inspcctor 5. Plwnbin� lnspecto�
G.O�hrr
C��nla¢t Penon: . --- PAonc p:
Informat�on and Instructions
Ats,sachu+ecu Gc�r+l[aws chapuer t 52 crquimc alt anployecs ro provide workers' compenaatioa for rheir en+pbyas.
Iti,�suant to�his u:uut0.����YK�s defuuad as`...avay perwn�o rhe service uf ano�hcc un.ia any concact of Aue. .
eapress ur impli�d.�xal ac urricttd"
�n��y,���a�"m ia�+dw4 P�P���'�ioo ar other te�l mdtY.or any nvo a mae
. n to er,or�he
oi�he foce�in�rnga�ed in a joim e�ueryrias,aad ioclwti�y<<he leeal represenadva ota deee:uai cmP Y
uWciatiou ar o�le�al cnatY.emDbY��+�W��Y� Nowever cGe
cecave ac nu��ee of m udividual.P�mec�P�' md wAo raida t�ei4 ar�he oocupsM of th�
owner of a dwellia�haus 6�vins not mae t�s t6res aparanmd
Jwelli�hause ot aaodiat who emPbY�P�rsoaa m Jo mainmmuce.awatrucdon ot repair work on wcA JweUia;houae
or on�he�n�or buil�na appwteeant t6aeto shall aa Seeaufe of wc!employmeot be deecmd w br m empbya.•
MGL clupar 152.42�(6)also smces timt"wery stW or beal lkeesht age�ey��ommo�edtY(er uy
reaewd of a Ileew or permk to openb a Aasiaan or b co�struet poi�disp
�ppq�es�t wM ras�ot pcodaced ueephAk evideae�o[covytluce wit►tYs Insura�a coverap requlred"
.�1JditiwoaUY.MGL chupter 152.423C(7)ata�ea"Neid�er tbe commonwealth oor mY of ia political abdivitioes ahall
����y� f��perfo�mance of puWic wort uncl aceepc�ble eviclanca uf compliance w i�6 c6e insuranoa
rcquiromrna ot i6is chaptar hsys tiecn presented w the connaetin;aud�ity.'
�pplicana
Pteye fill out the worlcep' cemansacon aPfidavit compkteb.bY cheelcin�the bozd�hat apply m your siWsaon aa4 if
nece+ao�'•�+PP�Y rubeoeuraccods)oam�(+��a)�P�°Wnba�(s)alon�with d�eir certificam(s)of
innvanee. Limital Ciability Compaaiea(LLG7 0[Limited Liability Pa�e�sh�W(LLP)wied no emploYad Wher than the
membus or purtn�n.u�n°����O cazry worlcm'compe�wrion insura�s. If an LLC or LLP does hsve
employees.n poliey is roquired. 8e advined diat rhis stTidavit may be submitced w the DePrrm�en�of Induaaia!
Accidenu for cooflnnstlon oP insuranae am'�raQe• Alw b���t to aiQs aod dute t6e�itfdavlt The utTidavit should
be retumed w che ciry or rown that�he applicuion for the penait a lieenx is being requested, not d�e Deparuaeat of
InJu�uciul Accidenb. S6ould you hava any questiod K�a�i��w or if you are Kquired co obtain a worken'
compenaacioa polity.Vkac�call ehe Bepmcm�etu ss�hm nue�Des leased hslaar. SelP-ins�sred companies should eater the'u
.elf-insurana licenae number on cha a tine.
cIry or Tow�Ortklab
Ptcarc bs wro thae che affida���ia compinte and printed Icgibly. The Deparrment has provided u spuca�u ehe botton►.
uf che affulavit for you tn fill ou[in the event tLe OtFee of Imestiyations has to wntact you reQudin�the app��cant
Pl�a� be suro w till ia�be p�rmit/ticenae num6er which will be used a.s s rrtcrrnce numbar. In addidun,:w apQlicant ��i
ih•rt muct submit muttipk pecmit/licenx apptSaaaons in any given yeaz,need anty submit one a�duvit indicadn�currooe I
policy information lif nectssary)�ruf u�dn"Job Site Addrcst"�he app�ca�t should wrifa"all la:ationr in (ciq ur
cuwn)."A cupY of the aflidavi4�h•rt has b��n offuiaUy stampc�t or muked by the city or town may be proviJcd co eht
applic:u�t aa proof�hsu a vnliJ atfidavit is on file for futurc permiu or licenses. A naw atFdavit mwu be tSlled out acb
yeaz. Whue a home uwtter or citimn is obuinin`s licenve or pmnit nat rclated to aay busiuex or commercial venturc
��,r,a,lu�1i¢ense or permit to burn leava eteJ aaid pereua u YOT requ'ued[o oomplem �his atYdavit. !
�•he O�iice ut Invtsti��[iuna wvuW ('ue w th�nk you in �dvanc¢ foc yout coopera�iun and shoulJ yuu h•rve:u�y questions, �
plc��e Ju nut hesince to give us a c�ll. I
Thc Departmrn�'s aJdress.celephone and fau number:
The Conunonweslth of Massachuxtts '�,
pepa�msent of In�uiat Accidents �
Odlet at[�wrttpflos� . , '
600 Wathin�oan St�et �'
Bostoa. MA 0211!
Tel. p 617-727-4900 e�ct 406 or 1-877-MASSAFE
Fa�c N 617-727-7749
Rcoi�cJ j-2G-US WWW.1n8SS.gOV/dli
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