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APPLICATION FOR
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f- --3 The Commonwealth of Massachusetts
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Department of Industrial Accidents
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600 Washington Street, 7th Floor
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit: Building/PlumbillizfElectrical Contractors
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Fl, f n L L
addrew
city Ph n #
work site location(Poll address)
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole 2roprietor and have no one workin in an ca acit . ❑ Building Addition
Milill
LJ-1-ant an employer providing workers' compensation for my employees working on this job.
- '16 w"i <
address: w,
city: h
d? `�
❑ I am a sole proprietor,general contractor,or homeow (circle one)and have hired the contractors listed below who have
the following workers' compensation polices: ._
company name:
address:
city;
IAS
nes n01fCy
company name:
address: ...
city: w:,
—TR i
n ___.. ...
Failure to secure coverage m required under Section 25A of MCL 152 can lead to the Imposition orerlminal penalties of a not up to$1,500.00 and/or
one years'imprisonment n well as civil penalties in the form of a STOP WORK ORDER and a ane of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
Ido hereby ceriify under e p 'ns an en ries of perjury that the information provided above is true and c rrecL
Signature Date
Print name Phone#
Llf
nly do not write in this area to be completed by city or town official
: rmittiicense a
P< _E1 Building Department
❑Licensing Board
mmediate response is required ❑Selectmen's Office
n: hone a; ❑Health Department
o
P ❑Other
o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
1ZO WASHINGTON STREET, 3RD FLOOR
1• SALEM, MAO 1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740.9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
-- - -- - of-Building-Permit#- --- — —all-debris-resultingfrorn-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 III, S 150A.
The debris will be disposed of at: /t/ s-
Location of Facility
Signah re ofPermit Applicant Datd
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL c1II, S 150A, and the building permits or licenses are to
indicate the location of the facility.