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CITY OF SALEM,, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. UEOVICZ, JR. TELEPHONE: 978.745-9595 EXT. 380
MAYOR FAX: 978-740-984E
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:
C , '��(Location of Facility)_/U � w�
ign a of Applicant
Sate
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ogee of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers
Applicant Information Please Print Leeibly
Name (Business!orlatuzation/individual): I�R L( P VM"W'SW/�GL 1 (3)4 1M1S<
Address: J70 � ZDilaz LI)
City/State/Zip• Phone#' S'7 2 —14 /
Are you an employer?Check the ` propreaoe boa: Type of project(required):
1.❑ I am a employer with 4: ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.01 am a sole proprietor or partter- listed on the attached sheet t 7. [v] 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 aria its.'
required:] i officers have exercised their 10"❑ Electrical repairs or additions
us
3.❑ I am a homeowner doing all work right of exemption"per MGL' 1].❑ Plumbing repairs or additions
c. 152,§1(41,and we bavc`no .myself. [No workers'comp: 12,0 Roof repairs
insurance required]t, employees. [No workers' ;
comp. insurance required j, 13.❑ Other
Any applicant that checks box#r muet also fill out the section below showing their;worken'corrrpensation policy infomratm
t Homeowners who submit tbie'effidavit mdicadn theyae doing all work and then hiid'o"utside mntigetoro roost submit a new affidavit indicating such
tContractots that check this box must attached an additional sheet showing the name of the sub-conlisciora and then workers'comp:policy information.
I am an employer that Is providing workers'compensadion Insurance for my employees Below Is tke polfey and job sfte
information.
Insurance Company Name:
Policy#or Self-ins.Lie. #: Expiration Date:
Job Site Address: City/Statezip:
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 ce nder the and penakin of p�eddy hat the Information Provided above is true and correct.
Si
QVicld use only. Do not write In Ah area,to be completed by city or town oAj4L
City or Town: PermittUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector S.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 person 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`" `
dwelling house of another who employs persons to do maintenance, construction or repair
work on deemed u h weemplolling hy house
or on the grounds or building appurtenant thereto shall not because of such employment
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall commonwealthholdthe
is for any ce r
business or to construct buildings in the
too operate s „
renewal of a license or permit p
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 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-conuactor(s)name(s),address(es),and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(I.LC)or Limited Liability Partnerships(LLP)with no employees other thaw the
members or partners, are not required to 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,sure to sign and date the affidavit. The affidavit should
be retuned 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 regazding.the law or if you at required to obtain a workers'
compensation policy,Please call the Department at the number listed below. Self-msured companies should enter their
self-insurance license number on the appropriate 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 fill in the permit(license number which will 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 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 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 5-26-05 www.mass.gov/dia
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