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The Commonwealth of Massachusetts .
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/•dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letably
Name (Business/Orprization/Indivithiso 6c1 yJ 6C G� !�J L fcS7 6C�.
Address: 7Z r,J(n AP d r_Jco
City/State/Zip: 19A c ' ' Phan#:r77- - 7�
Are you an employer?Check the'appropriate bor.` `;, Type of project(required):
1.❑ I am a employer with " 4. ❑'I am a general contractor and I 6. ❑New cons Wctioa
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet = ?• ❑ 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,iristrrance 5. ❑ We are a corporation and its;; IO.❑ Electrical repairs or additions
mg
required.] , officers have exercised their
3.❑ I am a homeowner.do all work Tight of exempnon'per Mt. 11.❑ Plumbing repairs or additions
self. o workets',co c. 152, 1(4�,and we have`no ,
my [N mp:, . _ § . ,, 12,❑ Roof repairs
insurance required:]t. employees. [No workers' , 13.❑ Other
comp. insurance zegtured]
•Any epplicmt that checks box N1 nine also fill out the section below showing their,wottea'compensation polity,information
t Homeowners who submit thie''affidevit indicating they are doing all work and then hiri outside contractors m6st submit a new affidavit indicating such
=Contractors that check this bui ttnrst attached an additional sheet showing the nane,of the'stib o roctora and their workers'comp•policy information.
I am a"employer that Is providing workers'compensation insurance for my er]iployees Below Is the polity and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State zip:
Attach a copy of the workers' compensation polley 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 S 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 certify b_ es u�that the informaton provided above is true and eorreeL
Siena nvr��- \ Date:
Phone#:
061cial use only. Do not write in this area,to be completed by city or town o,D4ciaL
City or Town: Permit/Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityirown Clerk 4.Electrical Inspector 5.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 like,
express or implied,oral or written."
An employer is defined:as"an individual,partnership,association,corporation 6r other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives pf a deceased ernployer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having of 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 such dwelling house
or on the grounds or building aPPurnnant thereon shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth or 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-contractor(s)uame(s),address(es)and phone number(s)along with their certificates)of `
insurance. Limited Liabmiity Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than 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 Depam mt of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that.the application for the permit or license is being requested,not the Department of
Indusuial'Accidents, Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy;please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license nmnbcron the appropriate lime.
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 pennivlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permmt(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 1mTe for future permits or licenses. Anew 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 lice to thank you in advance for your cooperation and should you have any questions,
please do of hesitate to give us a calla
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
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVIC2, JR. TELEPHONE: 978-745-9593 EXT. 380
MAYOR FAX: 978-740-9846
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:
(Location of Facility) __�v1 d
Signature of Applicant
Date