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CITY OF SALEM
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APPLIrATIM FOR
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- - _ - The Commonwealth of Massachusetts
Department of Industrial Accidents
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600 Washington Street, 1h Floor
Boston,Mass. 02111
Workers'C Affidavit: Building/Plumbipg/Electrical Contractors
name:
address:
JSY state: zip: phone q
work site location(full address),
❑ I am a homeowner performing all work myself. Project Type: New Construction❑Remodel
❑ I am a sole ro rietor and have no one workin in an ca aci Building Addition
1 am an employer providing workers' compensation for my employees working on thisiob
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add
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices.
com an n
add
city: nhone ik a
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4f�3"'a;�y"µ s.f1? J tN
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company name:
addrm:
city
Failure to secure coverage as required under Section 15A of NGL 152 can lead to the imposition ofcriminal penalties of fine up to$1,500.00 and/or
one yea"'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a flue of SI00.00 a day against me. f understand that a
copy or this statement maybe forwarded to the Office of investigations of the DIA for coverage verification.
l do hereby cert an the pains and penalties ojper)ury that the information provided above is true and orr a.
Signature _ Dale 5 �h
s
Print name D�'4 —`�-� Phone N
official use only do not write in this area to be completed by city or town omcial
city or town: permih'llcense N El Building Department
[]Licensing Board
❑check if immediate response is required ❑selectmen's Omce
❑Healtb Department
contact person: phone N; ❑Other
on,cw Szp,Lxul
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM, MA O 1970
TEL (976)743-9595 ENT. 360
FAX (976) 740.9846
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MM c 40,S34,I acknowledge that as a condition
of Building Permit# .all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c M S150A.
The debris will be disposed of
Location of Facility
Si of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
J� vA�c-,
Name ofI PParniit Applicant
Firm Name,if any
Address,City& St to
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or Strucdue be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or liceaaes are to
indicate the location of the facility.