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APPLICATON FOR
PERWr TD
TOGA TION
, �6 ale s
PERMT OPANTED
APFWMW
MrBP
'.. I Feb 24 06 04: 44p Darrell Gonyea 976-282- 1527 p. l
i
f
The Commonwealth of Massachusetts
Department of Industrial Accidents 6
Office of Invemkidons
j 600 Washington Street J
i Boston,MA 02111
www.massgov/die
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumbers
Applicant Information Please Print Ix¢i'bly
Name(gu oo/Iadivi": (r y
r� {
Address:-
phme#'. ', 7G /
I E Are an an employer?Check the appropriate box. Type of prolat(required):
1.YJ i am a employer with t 4. ❑ 1 am a general contractor and 1 6. ElNew construction
employees(fill andlor part-time).* have hired the 7. Remodeling
' 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet r LI
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 corporatidn and its 10.❑ Electrical repairs or additions
required] officers have exercised their
3.❑ I am a homeowner doing all weak right of exemption per MGL' 11.❑Phrmbing repairs or additions
myself[No workeW comp. c. 152,§1(4X and we have no 12.❑Roof repairs
i insurance roquimLl
t employees.(No workers'
comp.insurance require&& 13.❑ Other
. *Any applicant dw ebedo co uo x Nl vmek d M out the sccdm below showing thau;wu,lQn'corapesadm policy iafomte8ou
t Homeownm who atesit06 affidavit indication they eve doing all work and d m hire outtdde conksrdurs most submit a new affidavit Wwwring such.
tcmnactors that cbeek this box non attached w addiaonel chat ahowtag the nma of she ealvmatrapaa cad their workers'cmvp.policy mfotmeuoa
I am ap empkyerthan hpmvldhta tvorkm'eompmmdm tnswwwefor my emPhOvm Below h thepakeyandjob she
lnformadow n
insurance company Name: L4 GH /7 -7e/Z,`Cc,
.
Policy#or Self-ins.Lic. #: �-3� [G 3 8� Expiration Date: /6
Job Site Address: >'- �'/c r =� City/State/Zip:
Attach a copy,of the workers'compensation policy declaration page(showing the policy number and expiration date).
Fail=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 S1,5oo.00 and/or one-year imprisonment,as wen as civil penalties in the form or a STOP;VORK ORDER and a tine
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
I investigations of the DIA for insarance coverage verification.
I At hereby cen&under dwpahn and penalties ofperjwy Neat the htfonnadon providedd above h true and correct
i
-� Date: i ' o
Phone#: c�s',3'� :: Cv
Opiclat are a* Do nor wrke Is thh area,to be completed by cry ofAMM oofekl
i
City or Town: PermiNJanse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
I
Contact Person: Phone#
CITY OF SALEM MAS r SACHUSETTS
PUBLIC PROP
ERTY DEP
ARTMENT
120 WASHINGTON STREET, 3RD FLOOR
ce
SALEM, MASSACHUSETTS OIS70
STANLEY J. USOVIC2, JR. TELEPHONE: 978-745-9395 EXT. 380
MAYOR FAX: 976-740-9846
Salem Buildina 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 b MG
Chapter y L
p III, S 150 A.
The debris will be disposed of in:
(Location of Facility) /,
Signature of App
-13 — e,�� �
Date