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BUILDMw PROW APPLICATION FOR:
Permit to:
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PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undero gned hereby applies for a permit to build aoowft to des foOwmg
OWWS Nam•
Address a Phone
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Address & Phone - j 1
Mechanics Name s ,
Address a Phone 02-
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SW= UNDER PENALTY
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DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: ��nl?
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The Contntonwealth ofM"saenusens
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www ou"gowlie irid_
Workers'Compensation Insurance Affidavit: Buflders/Contractors/El ease I'ri>od Legibly
A B n Informatlo
Name
Ate• , a 3v 2 5 J
0/ 5 /
city/Stag:
Are y employer?Cheek the approPrlue box Type of proJeet(►Mired):
4. I am a general Contractor and I 6. New construction
1.pl ems(fa with• have hived the sob-eoubaclon
employoea(fltll and/orparFtime). 7. ❑ Remodeling
2. listed on the attached sheet t I am a sole proprietor of partner- Tbese sub-contractors have S. ❑ Demolition
ship and have no empbYea works. enmp. inn UM 9. ❑ Building a&Won
working for me in any capacity. 5. ❑ We are a corporation and its airs or additions
[No.�� insurance their 10.0 Electrical rep
ralnitmd 1 right of exemption per MGL 11.0 ing rcP� or additions
3.❑ I am a homeowner doing all work
c: 152,j1(4),and we have no 12.[ Roo f repaua
myself [No workers camp• e m toY�, [No workers'
insurance required.]t Cop ormance m9»a�) 13.0 Other
Any sPP>Ut 1kN cbccb twx Nt out elan fill out Se eectien be sU wok sod 16eo>me audtdCoubde' cootrrton mnR mbn*a m�afi&vit ioding suck
t'Homww wn VAM s and d&affidavit i dwy domf
tCopttaMn am chock tills two me stteeked an additions,skeet ekowma eke none of Poe subcontradaa sod dolt woken'comp Policy mfonranm
am as employer that is pmWdi t;workers'compensadoa laswrenee for my employees. Blow h the polity eadfob slit
lnfartnatten _
Insurance Company Name: —7
Policy#or Self-ins.Lie #: G G G 3 Expiation Date:
awstate,20. c/ .
Job Site Address: "
Attach a copy of the workerscoopen' ndoa policy declaratloa page(showing the policy number sad expiration date}
.
covers as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Fa7u p n secure coveragent.as wen as civil penalties in the form of a STOP WORK ORDER and a tine
fine up to$1,500a d and/or st th ear impri. Bea dv t be forwarded to the Office of
. H advised that a copy of this statement may
f to$250.00 a day against the violator.
o up
Investigations of the DIA for iaMrMC coverage veriScatian•
I do hereby cen* cad penzwes of Information p wikd above Is and
o• eAd rare mrlp. Do not wrist in this area,to be coayplsted bl elf'ormwa O ldat
City or Town: PermWUaese N
Issulag Authority(drde one):
1.Board of Health 2.Building Department 3.Clty/Ibwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone tY:
lB A%FA aaa{a6aVaa 44JLA%a 1JuL061 sa\ 16A%pa La
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an eaip/eyee is defined as"...every person in the service of another under any contract of Lire,
express or implied,oral or writaa"
An eoWle err a defined as"an individual,partnership,associate^corporation or other legal entity,or any two or tmore
of the foregoing engaged in a joint eataprise,and including the legal representatives of a deceased employer,or thin
receiver ortrustee of an individual,partnership,association or other legal entity,employing empbyeen. However the
owner of a dwelling house having not more than three apartments and who resides thaem,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair wort on and dwelling home
or an the grounds or building appurtenant thaeb shall not because of such empbyment be deemed to be an UnPbyes."
MGL chapter 152,§25C(6)also state dui"every pate or local licensing agency shall wkhhold the Itsuaeee or
renewal of a license or perm@ to operate a business or to eoaatruet buildings In the commonweda for any
apptlead.wbo has not produced acceptable evldnee of complince with the inss ram coverage requizvel."
Additionally,MGL chapter 1S2,125C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enw into any contact for the performance ofpublic work until acceptable evidence of compliance with the insurnm
requirements of this chapter have been presented to die contacting authority:"
Applicaab
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 mmsba(s)along with their ard6cate(s)of
insurance. Limited Liability Companies(LLQ or Linear Liability partnerships(LLP)with no employees other thou the
members or patinas, 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 Indusaial
Accidents for confirmation of insurance coverage. Also be acre to sip and date the affidavit. 'Ile affidavit should
be returned to the city or town that the application An the pant or license is being requested,not the Departnent of ..
Industrial Accidents. Should you have any questions regarding the law or if you an required to obtain a workers'
compensation policy,piease call the Department at the nomber listed below. Self-insured companies should enter they
self-insurance license number on die appropriate lift
Clty or Town oflidals
Please be acre 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 sore to fill in the pamidticcnse number which will be used as a reference number. In addition,an applicant .
that must submit multiple P==Vhcense 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 supped or,marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fhtre Paulo or license. A new affidavit must be fined out each
year.When a home owner or citizen is obtaining a license or permit not related to any business of comn=cial venture
(i.a a dog license or permit to buin.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 donut 5esitstilb give us,a call.
1Le Department's addrraa,telephone,and fax number.
The Commonwealth of Massachusetts
Dgwtmeat of Industrial Accidents
Office of InveSdgatlotu
600 Washington Strut
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
A 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildiny,Department
Debris bisposal 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
y as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
�/
4X (Location of Facility) r`—l� l C'
Z
Signature o t
G S
Date