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PERMIT GRANTED
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CITY OF_SALEM
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TO THE INSPECTOR OF BUILDINGS '.
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Mhitaot's Name
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1Vsme olPamit Appdc&
Ffrm Name,if my
Ad*dW City A SUN
Mw Am su ft requires tbet debris Qom dw damotibM rmovaew% raeab or odw
Wtalb"otbaift or sttucam be disposed a a popaly-k add solid-waw diRow
fikdLty ere de&W by MM dlL$15ft and the hdldmjPermit►or liemset m to
iadfcaoe tbo beadoa oltlso lbeitiry,
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veparrMear of tnausr 141 ACctaenra
Offlce of lAwsligadon
600 Washington Shed
Boston,MA 02111
www,nrascgol✓dia
Workers'Compensation Insurance AiSdavit: BuHdemContractora/Elect idansMumbers
ApOcant Information Please Print LesMy
Name
Address:— tie ,,�
City/StatdZap: .Su �T ✓h�9, al q c) Phone# _ l 1 �� 7 y f�
Are you as employers!Cheek tile-appropriate box,. Type of Project(required):
i.❑ I am a employer with 4. ® I am a general comasclor and 1
2.❑ I �(thD and/or parfrtime}
• have hired die sub-aombaclora 6. ❑New construction
proprietor or partua- lined on the attached sheet t 7• ® Remodeling
ship and have an employed These sub-contracm have 8. ❑ Demolition
working for me in any capacity. workers'coup.immnce. 9. ❑ Bm7diog addition
[No workers'comp.insurance 5. ❑ We are a corporation acid is 10.❑ Electrical en
oftets have exercised their rW additions
3.❑ Ir��lwmeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or addition
myself [No walkers' comp. a 15Z 11(41 and we have no 12.0 Roof repair
insurance 1 1 I)t employees. [No vollm, 13.❑ O&a
comp.immam required.]
;Any applicant ma ahecb cox el mug aLo rift out ma section below atnwina mdr wwtheea'••than ter iasoeMotios
ltotowwoces who submit Thin affdhvat iodkews mey an dome•a work and men here at d&comkton must eubted a new dfidevit mdieetfna such
tConow%=ON check rots box must stladntad an addituoal abeet abowtoa me nanm of del abaoebae6ae axes rev wo&m'cane.lwliy inforrnrtiea.
I am One employer that is prowl%W workers'compemodon has gme jor my employees Refow is the paUV a djob slat
lnjonnarloa
Iasmamx Company Name: -);4.g i 1_fir 5 T
Policy 0 or Self-ins.Lic.M__�� ( . _'7 Expiration
Job Sim Address: �,L A CA i2 S7- S,q yv/ City/State zip: Sd9L� /;/# . 0197O'
Attach a copy of the workers' coull"utloa policy deelsratioa Page(showing the Polley number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can Ind to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil peoslod m the form of a STOP WORK ORDER and a fro
of up no$250.00 a day against the violator. Be advised that a copy of thisnal statement maybe forwarded ye-the OtiflE a
Investigations of the DIA Sir msurmce coverage verification
I Al kereby ceno Nader tits pdas end pensida ojperJrry that Ad bejerma*x prwlkd above 8 arms and carreet
Dale•
Phone N �97 �) 7�/f —4/4/w
O,olcid ass only. Do nd write 1N tM area,to be eompWd by co or Amu ohkid
City or Towm PetwN/Loeore 0
Issuing Authority(circle osep
1.Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Pawn: Phone 8
Laws chapter 132 requires all employers to provide workers' compensation for their emPioyaa•
Massachusetts General isdefined as"...every persoa in the service of another 11 any contract of hire,
pursuant to this statute, an eNW10Ya
express or implied,oral or writua."
An esrpfoye>•is defined as an irdi al.P�mb*associWM coition°r other legal entity.or any two or mote
of the foreping engaged in a joint eaterpri.and including the legal nprercatatives of a deceased employer,or the
receiver or trtpue of an individual,parmesft astociatwn or other legal entity.OVIDying employ however the
owner of a dwelling house more three apattmems and who resides therein,or the ooapmt of do-
house bavbg
lays Persons to do maintenance,construction or repair work on sack dwelling house
then ants m "
of anu darned b be emP�r•
dwelling house *crew abaD not because of each empbymmtbe
the er budlding '
or on grounds
MGL chapter 15Z 125C(6)also states that"every state or local licee t sLeuym shall
the mmsawh or
at of a deeate or Per unit to operate a bwhM or to conWnet building
who Yea swt P�ns�aaeptabk evidence of eompllsace with the Missives eon regahred
'Nasally.o h ca pro 1sced SC(7)states"Nei&&the commonwealth uw any of ib potided subdivisions sba11
of hip woult until acceptable evidence of compliance wi*the
tolurrOMM
eater into my contract fbr the pertotmsece Pub
requirements of this chapter bave been presented to the contracting=tho*-*
APP>kanta - lion and,if
please fill out the workets'eongmsatioa affidavit completely,by chaddog the boxes that apply to your aims
necessary,supply sub-Contrac0ot(s)namdst address(es)and phone mmiber(s)along with their eati&ate(s)of
insornot. Limited Liability Compaaia(LLCM or Limited Liabil Y partnerships(I.LP)with no employees other than this
members or partners,are not required to tarty wodkerf'compaosation hunmence' If an LLC or LLP does have
employees,a policy is rcquhv& Be advised that this affidavit may be submitted tu the Departticat of hidostrial
Accidents fan eem8rmstion of insurance coverage• Also be sue to sip sad date the atfldavk. The affidavit should
be retiirnod TD the city or town that the application for&e permit or license is being requested,not the Departuneet of
Industrial Accidents. Should you have any question regmdiot the taw or if you are required to obtain a workers'co�scnaatia Ipobey.Ple ee can the at the number listed below. Self-baured onmpxdw should eater their
self inseumce license mmaber oa the tiers
Cky or Tows Olnda s
Please be carve that the affidavit isMete and Printed legibly'. The Department bas Provided a space at the botmm
of the affidavit for You to Ml out in the event the Office of Investigations has to contact you regarding the applicant
please be sure to Im in the p=&Scame number which will be used as a reference number. In addition.an aPPllAnt
one atHdavit indicating current
that moat submit multiple permv/hcense applications in any given Peer,need only submit
policy information(if neceasauy)and under"Job Site Address"the apphcaun should write"all locations in_(city of
of the atffdsvlt that ban ban officially stamped or marked by the coy or town MAY be Provided to the
town)."A copy of licenses. Anew affidavit mast be filled out each
applicant as proof that a valid affidavit is on Me for fitture permits not Belated to any business or ootimiercisl ventureyear.Where a home owner eg titian is obtaining a license a permit
(ice a dog license or permit to bum leaves etc.)said person is NOT required to camPleoe this affidavit
The Office of Investigations would]lire to thank you in advance for your cooperation and should you have any questions,
please do not besitate m give m a call.
The DepartencaYs address,telephone and fax number.
The Commonwealth of Massachusetts
Depz=ent of Industrial Accidents
office of Investigations
boo 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