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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 340 FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9895 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Deuartment
Debris Disuosal 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:
4S�C ma n w \I (Location of Facility)
Signature of Applicant
1
Date
s ✓JEe 1!aommanraem� o�./�amac%uoella. .
BOARD OF BUILDING REGULATIONS
License:!.CONSTRUCTION SUPERVISOR
* Number CSC 062497
':_'� BirthdSte �91451}958r �. ��.
Ezpi[egi 09l05/20p7 Tr.no 11163 +' 1
< ResVI�CQhR% 'Q
ROBERT J MANIEt+i -�xyf -�
28 AUBURN ST
WOBURN, MA.01801"^C.., ir` Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
660 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information "'° " Please Print Leiibiv
Name (Business Organization/In(ividual) U
Address: O(Do Su L O ;0= �S `
City/State/Zip: >„ �r'kb Phone bt: (el 7 ^ 9 77< 17o
Are you an employer?Check the appropriate box.° "^ Type of project(required):
4`. ❑'I am"a general contractor and I
1.❑ i am a employer with 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-coutractors ,
2. I am a sole proprietor or partner-
listed on the attached sheet. $ ?• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working.for me in any capacity, workers' comp. insurance. 9.,,❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its. 10.❑ Electrical. ,
required.] t , v, .,
officers have exercised their repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL` 11.❑ Plumbing repairs or additions
myself. [No workers'.comp. c. 152,§1(4);and we have"no 12.❑ Roof repairs
insurance required.],t, employees [No workers' , 13.❑ Other
comp.insurance required.]`",
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContrectors that check this box must attached an additional sheet showing the name of the sub-contticn s and their workers'comp:policy information.
I am an employer that is providing workers'compensation insurance for my employees."Below is the pollcy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: /Zic S}, City/State/Zip: S4
Zzw
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties edury that the information provided above is true and correct:
Suture �`'- � Date: zZla1o(c:>
Phone#• Lp 7 7CjS:
O,fjrcial use only. Do not write in this area,to be completed by city or town of tcid
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
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,per son in the service of another under any contract of hire, ,
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,k'`
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 cormonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public 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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
eq
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation covers
'on of insurance e. Also be'sure to sign
and date the affidavit. The affidavit should
g
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 lime.
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 the pemrittlicense number which will be used as a reference umber. In addition, an applicant
that must submit multiple permittlicense 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
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 as 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-NIASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia