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APPLICATION FOR
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PEFWT GRANTED
77.
INSP6 F BUL DINGS
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. U80VICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
/7-L (Location of Facility) PC24(2
Sig a of Applican
Date /
,per The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations.
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Bunders/Contractors/Elec Pleasepal Lenirs
A :Can Information J
on/Individasp 1 �S LLC—
Name(Bum
Address: l v� e c( Vi-- # C; I —
City/State/Zip:L o--1 d fit^ /J°` v'Le 4-9 Phone M '7 S
prsbip
employer?Check the,appropriate box: Type Ptoi�( °��):
etrrployc with 4• ❑ I am a gentxal contracror and I 6. Nrw consamction
y«s(fun and/or part-time). Lave hfred tLe sub contractors ? ❑ Remodeling
listed on the attached sheet t2 sole proprietor or partner- These sub cantracoors Lave8. ❑ Demolition
and have m WVIOYM workers' comp. insurance. 9. ❑ BuMing addition
working for>nc in any�pY 5. ❑ We are a corporation and its
[No workers'comp.ius�uanca ME] Electrical repafrs or additions
officers have exercised their
requfrcd]
right of exemption per MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing an work
o workers' comp• c: 152,§1(4),and we have>m 12.❑ Roofrepaus
myself. [N
insurance wor employees. [No workers' 13.❑ Other
comp.insurance required.].
bcmt then cbecb box#1 must also fill out the sediae below showing their workent convensawn poluy mf°rmaLoa
-Any app ere doing all work and than hire outside mnVectota must submit a new affidavit indicating such.
t Horneowvers who submit tbie dfdavit iedieatina they the name of the sub.-contractora®d their wotkae come•polity mfor moon•
tl;onttacama the check this box must an0eched en additional rhea slgwing
I am an employer that is providing workers'compensation Lrs Iuronct for my employees Below fire policy sndJob sits
Informallom
Insurance Company Name: "X-GSA-t - Z) INS
Policy#or Self-ins.Lia#13 ( 06 Gal-6) 91 off— Expiration Date:
Job Site Address �l `— �� � City/Staw7ip: �Aj
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
e' sition of criminal penalties of a
L c. 152 can lead to Tb mho
required under Section 25A of MG
Failure p to$1,50 coverage as W as well as civil penalties in the form of a STOP WORK ORDER and a fine
fine up to S 1,500.00 and/or ono-year imprisonment,
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tie Oil+ice of
Investigations of the DIA for instttance coverage verification•
I do baeby andpenables of perjury that the injbrmadon provided above b true and correct
S'
#:
pfjicial ast onl}s Do oat ws b !r this area,to 6e eoarpJeted by eiy ortorvn oo9e/aL
City or Town: PermillUcense#
Issuing Authority(circle one):
1.Board of Heakh 2.Building Department 3.Ckyrrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
11a1 V1111N1iV>i anal la iliO4l Kva.lVilO
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hfre,
express or implied,oral or written"
An 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 than 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."
MGL 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 ofpublic work until acceptable evidence of compliance with the insurance
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-contractors)name(s),address(cs)and phone numbers)along with their certificatc(s)of
insurance. limited Liability Companies,(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required tn 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 son 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. Self-insured companies should enter their
self-insurance license number on the appropriate fine.
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 die pemmidlicense number which wm71 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 of the affidavit that has been officially or marked the or town»fY �Y�M by city may be provided 10 the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be frilled out each
year::Wbere a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ie. a dog license or permit to bum 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 fax 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
Fax#617-727-7749
Revised 5-26 OS wow mass.gov/dia