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CITY OF SM EN1, INUSSACHLSETTS
BUILDING DEPARTMENT
• + 120 W.kMINGTON STREET,3-FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KI\IBERLEY DRISCOLL
MAYOR Two ST.PEEaRe
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 9 Please PrintLegibly
Nam e(Busiar ,C)rganintion/Individual): �+//V/�' 2 /4-
Address: 6 Jt:M%C P/13Ce
city/state/zip: s4elm non 0/010 Phone 97.V- ?As-d6/0
Are you an employer?Check the appropriate box: Type of project(required):
l.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sib-contractors t-,
2.Et t am a sole proprietor or partner- listed on the attached sheet 1 y- lid+remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required,) officers have exercised thew 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 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' 13.0 Other
comp.insurance required.)
•Any appliam that checks box ill must ado till uut the section below showing thsdr worker'wmpemadon policy mien and m.
'1 hxneowmxs who submit Chi,affidavit indicating they am doing all work and then hire onside contrscruca must submit a new articinvit indicuing such.
Tumrocdon chat check this box most attached an additional shad showing the name ottha subtontractom and their workers'comp.policy information.
I am an employer that It providing workers'compensation Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
lob Site Address: 30 �U/t'Ifl/er to City/State/Zip: Dqw ;W
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 imprisonmenq as wall 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
Investigalions of the DIA for insurance coverage nrification.
I do hereby certify under the ins and penalties ofperjury that the information provided above is true and correct.
Sitzriatu,c=- i Date' -7122
Phone
Ojlcial use only. Do not write in this area to be completed by city or totun official
City or Town: Perm[t/l.icense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Citylfbwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other,
Contact Permn: Phone#:
1
CITY OF S. .FNl, IN-WS.-.CHUSETTS
• BUILDING DEPARTMENT
120 WASHNGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJtBERI.SY DRISCOLL
MAYOR THosw ST.PtERRe
DIRECTOR OF PUBLIC PROPERTY/BU UMLNG COJLUISSIONER
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:
(name of hauler)
The debris will be disposed of in :
JryrP/1✓1 T 9`0- V?9A iS
(name of facility)
SfNH1��SLaIr /10
(address of facility)
s' atur f permit applicant
date
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