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CITY OF SM-EANIJI NIASSACHUSETTS
• &ILDLNIG DEPARTMENT
• 120 WASHINGTON STREET,3'n FLOOR
TFL (978)745-9595
FAX(978) 740-9846
KIABEM EY DRISCOLL
i�AYOR T�ioivtAs ST.PtFARIi
DIRECTOR OF PUBLIC PROPERTY/BuI DLNIG co%M ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lettibly
Name(Busimess.OrganizatioNlndividmi): U:sl
Address: �?7
City/State/Zip: Sn1em a 19 30 Phone #: `!�� 7YI- 1/2Z fs
Are you an employer?Check the appropriate has: Type of project(required):
1.❑ lam a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors Fyn
2.El am a sole proprietor or partner- listed on the attached sheet.t 7. tot•remodeling
ship and have no employees These sub-contractors have ll. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
aired.) officers have exercised their 10.❑ Electrical repairs or additions
3.U I am a homeowner doing all work right of exemption per MGL I 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' 13.❑Other
comp. insurance required.]
•Any appliauu that checks brae#1 must also fill cut the secliou below stowing their workers'compensation policy information.
*tinmeowners who submit this affidavit indicating they am doing an work and then hire outside contractors must submit a new affidavit indicating such.
=Conrra ton that check this box must attached an additional sheet showing the name of the sub<omractom and theh worker'comp.policy information.
I am an employer that it providing workers'compensation insurance for my emplayees. Below is the policy 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 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 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 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.
i do hereby certyy under the pains and penalties ajperjury that the information provided above is true and correct
Sienaturc' -14i Q „an^w '1 Dole- 7 ff--
Phone
Official use only. Do not write in this area,to be completed by city or town ofjrciaL
City or"rown: PermittLieense#
Issuing Authority(circle one):
1. Board of stealth 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.O ther ,
Contact Person• ____...... Phone#:
CITY OF SALE.ti1, NL SSACHUSETrS
Btin=NG DEPARr.MNT
130 WASHINGTON STREET, 3' FLOOR
• 'ILL (978) 745-9595
FAX(978) 740-9846
KI,,SSERLEY DRISCOIl
�YOR TriObtAS ST.PIEttRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COWNIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
_ CX-1 In In r
(name of hauler)
The debris will be disposed of in :
(name oJf/facility) /
�U�[I SY oll wl �(OM
jaddress of facility)
signature of permit applicant
-S -U 3
date
dcbn.wIl.dce