9 SYMONDS - BUILDING INSPECTION (2) r
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensadon Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Applicant Information Please Print Legibly
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Address:
cily�sl��z�psfi�lz�i '�r /l% (Rhone#.
Are you an employer?Cheek the appropriate bons Typs of project
1.[3 1 am a employer with 4. ❑ 1 am a general coWtaetor and 1
employe"(full and/or part-tinge).• have hired the sub-comractors 6. Q New conrttuctioa
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑Remodeling
ship and have no employees Theca�have g. Q Demolition
working for me in any capacity. workers'comp insurance. 9, Q Building addition
f too workers'cants. insurance 5. ❑ We am a corporation and its 10.0 Electrical repairs or additions
officers have exerciser!their
3.Q 1 am a homeowner doing all wait right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,J 1(4),and we have no 12.0 Ruotsepaia
insurance iaquircd.] m cmployccs.IA'o workers' 13.0 Other
comp inwrarlcc required.]
•Any 4pp6eud aM doacks boa 01 mm also rill man dw aerie bdow tlaamriea alteir wtakee' Pulley iarwmaaiaa
'I jw wmmroo who subalil eY amdsvit lndkaaola coy an;doias an Wofk 011110110011 bile owelde 4MCackn anon•utomit a new amJevit ijk iaalna"h.
-CuMrkaaam thou steak eus boa mug amrlaeJ as adeai mrl alMl Jwwity We naaea of ace and their warkela'canny.policy 1116111nan11o,
/uw tin eetp/oyer that 6 provld/nf worker'compensat/oa livaranes jog my gets/oyes? Below is the polity and fob site
iufwwatfan,
Insurance Company Name:
�' CCam--• _ - --
Policy Nor Solf-ins. Lic.d: �� h __. Expiration Date:
Job Site Address: citylstuteizip:
Attach a copy of the workers' compensation paalky declaration page(showing the policy number and expiration date).
Failure to sccurn coverage as required wider Section 25A of NGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fma
of up In S2 .00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
luv.anga was I"the DIA for insurance covcrayc verification.
4r !,v y,/anydre the pr ash �buhk:ufperJary that Moe inforarwfon provided ubaswW true and correct
_✓.l 134Ie' I V
U are en/yt Ae eat write/it tk/r area,to de raaapteteafby dry or towte of ei'd
City or Town: PermittlJccnse It __.
Issuing Aulhurity (circle ouc):
1. Iluard of llealth 2. Building Department 3.Cityirown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: _ Imhons p:
n
Information and Instructions
,,Ius,rchuscros Gcncral Laws chapter 132 requires all employers to provide workers' compensation for theirempbyeV
Pursuant to this statute.an ew'fayee is defined as`...every service person in the serve of another under any contact of hire.
eapress or implied,oral or written."
An aeobl`e►is de8sed as-as ind�panaenshtp.amodadak Corporation err other legal entity,of any two of more
Of the foregoing engaged in a joint entetprits,and including the legal reprssenrad es eta deceased employer,or the
astoeiation err other legal ctcity,employing employees. However the
receiver a dusters of o se having
of rose hap. and who reside tberein,or the occupant of the
owner of a dwelling bouts having not rrmore than three apartmnmts
dwelling house of another who employs persona to do maintenance•construction or repair work on such dwelling house
or on the grounds at building appurtenant thereto shall not because of such employment be deemed to be an employer»
MGL chapter 152.423C(6)also states that"every state or beer!lieetssiug ageaeyAM the om hold the issuance or
for any
es
renewal of a lleease or permit to operate a bustas or to construct btdldtap m
epptkant who has set produced acceptable avides es of eomptlaaee with the Insurance coverage required"
Additionally.MGL chapter 152,423C(7)states"Neither the commonwealth not any of its political wbdivisioes 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 sad if
necessary,supply sub-contractor(s)name(+),address(es)and phone ournber(s)along with their cerrificate(s)of
insurance. Limitsd Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or prcuumi,are not required to early waken'compensation insuranee. If an LLC or LLP does have
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Abe 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
Industrial Accidents. Should you have any questions regarding the low or if you arc required to obtain a workers'
cormperuuion policy.piease call the Department at the number listed below. Self-insured companies should enter their
.self-insurance license number on the appropriate line
City or Town Off elsk
please be sure that the affidavit is complete and printed legibly. The Department has provided a space at bottom.
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the APPlicanL
t'leasc be sure to till in the permit/licnse number which will be used as a reference number. In addition,an applicant
that most submit multiple permitilicense 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 file for future permits or licenses. A new affidavit must be tilted out each
year. Where a home owner or citi=n is obtaining a license or permit not related to any business or commercial venture
t i.e.a dog license or permit to burn leaves cteJ said person is YOT required to complete this affidavit.
I'hc Oi six of lnvcstiyatiuns would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Indust W Accidents
0 of Iewsdgadeea
600 Washic0on S&M
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
,tcvised 5-26-05 www.mass.gov/dia
EITY-OF
PUBLIC PROPERTY
DEPARTMENT
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1.0 WM INFORMATION
Location Name t?IUlldtr :
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AW0110 Is locabd Ina;Corwrva*m Area YM & Mlofb DNIrkA YM
EORz;Ft1P INFORMATION
Owner of Land
&0 COMPLETE THIS sECTION FOR WORK IN MUSEM BUILDINGS ONLY
Addition Existing
Renovation Number of stories Renovated
Change in Use New
Demolition Existing
Approximate year 1of
Area per floor (at) Renovated
construction or renovation
of existing building New
tilde(Descripdon of Proposed Work:
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Make sure that all fleids are Property and "aY to avoid delays in p rI4
Th.und. Wied doe.spy apply for a euudinFPto ►uild to .stated
Signed under penalty of t OLOa� /� 6
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