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PUSUC PROPERTY DEPARTMENT
• 20 WASH1NQfON sT119" 311D FLoo11 .
i- ` SALEM,MA O 160
TEL (978)745-9595 EXT.390
STANLEY J. USOVICZ, JR FAX (979) 740. S"
MAYOR
DISPOSAL OF DEBRIS AFMAVrr
In w=rdaaoa with the Provisions of MGL c 40,S34,I`ackwwledge that as a condition of Bnildiag Permit* all debris iesultin5 from the
governed by this Building Permit SW be disposed of in A properly licensed
disposal facility, as deftoed by MGL c h$S1SOA.
4be debris w$1 be disposed of at B F �� , o 1.
Location of Fsamy
Slgnaturn of Permit
Date •
FULLY complete the following iagimistiom.
(PLEASE PRIMP CLEARLY)
Name of Pewit Appfioutnt
Firm Name, if any
Address, city&State v
The above statute requires that debris from dre demolition, renovation,rehab or otba
alteration of building or structure be disposed in a li
fiality as de5ned by MQ c1II, S 130A, sad the bull y- cam so"waste disposal
indicate the location of the faciI4. permits a licenses are to
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): L P ✓ l i b o L C bt.s T
Address:- `I q n'1 A t:J ST'
City/State/Zip�,e n bnp A O 14t;D Phone #: -73 S 3
Are you an employer? Check the appropriate box: Type of project(required):
&J am a employer with /_r5 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, t ? ❑ Remodeling
ship and have no.employees These sub-contractors have 8. ❑ Demolition
,I wolking for me in any capacity. workers' comp. insurance, g, ❑ Building addition
+. [No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
0 I am,p homeowner doing all work right of exemption per MGL 1 I.❑ 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'
comp. insurance required.] 13.❑ Other
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name: fl M. U� V /1 C, ( ��
Policy #or Self-ins. Lic. #: t7C-) g �1 �� (0 1 ) Q0 S Expiration Date: �.
Job Site Address: � � Ai/Pv.� A City/State/Zip: -S izL m _
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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.
/do hereby certify under the pains and penalties ofperjury that the information provided above
is true and correct.
Signature (� 1pp.7•�--E',.B�O� p Date:
Phone
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PertttjtgLicense#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk_ . Electrical Inspector 5. Plumbing Inspector
6. Other s;
Contact Person: Phone#: