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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BMG GRANTED
BuildingPeradt LoeatiaaofHuildiag SSD U/a! tiy�aa f �/9
APpflatioo For
'(Circle wbkham applies) Roof; WWI Siding,Coaaw Dodd Shed pool
Addition, iteration,RepaedRaplace.Fau a ion Only.Wtet k4
other.
PLEASE FD L OUT LEGIBLY& COMPLETELY TO AVOW DELAYS IN PROCESSING
To too Iwpoaor of Bwminp.
The wWmaigpW bmeby applies/for,a1� permit to build a000rdiog to the bollowins apocifladow
Owom'fr Name: u/Za i !�/l 6 N c
City fd'/"7 Stratp0/�o.C.
Phowa ( ) Sate Phone(9,4) 2i 1�'Gkee
Arebhm:_ dlIx City of Saba UdL / G 9
Sonxt Ciq' State LkrY O/#H�M ti/4
state Phu= ( ) Homaowmen Exempt FormL..)ea ✓no
StrrcWte:(pleam circle) Single Family. Mull Family# 3 -Otber
Estimated Cat of job S 14111000
Will bwwing rt! w. tq
Asbeatoo!_;_yano
Daerip&W of work b be done:- Z r-c-1-i a
_4 L Gl i'4 r/'7 / /
Dmwimp Submitted:rya_✓ no Mail rank to:
�� o,C .2— ��.�./7
paWrc of ApP�m NED UNDER THE PENALTY OF PEIWRY
CONSTRUCTION TO BIWOMPLETED WITHIN SIX(t)—MONTHS OF PERMIT ISSUED DATE
Department use only: pwu*1 r_,^
Permit bee
cOtilrs:
I nc a.rrrnmrrn NGYfIn VJ!r/aSJal:n1[JGRJ
Department of Industrial Accidents
Office of Investigations
- N 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
AuDlicant Information �J / Please/Print Leeibly
Name Mus n ss/organivationandividual): i/Y�a�//ia n-w l �do�/tici z:1,V1 6 Al G
Address: l/X- ,Z Z
City/State/Zip: z 7 6/ Phone#:97� 2y � - /, ���
Are oa an employer?Check the appropriate box: Type of project(required):
1. I am a employer with. �' 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(fan and/or part-timc).• have hired the sub-contractors
2.❑ I am a sole proprietor or parmer- listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working far me in any capacity. workers' comp.insurance. 9. M Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its • .
required.] officers have exercised then 10❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.U—Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp.insurance required.]
•My applicant that checks box#1 nwa also fill out the section below showing ibe r workers' Lion policy mformshm
t Homeowners who sabred this affidavit i Ld,,tiog they are doing ell work and then hire outside contractors must subrmt a new affidavit indicating suck
tContractm that check this box must attached an additional sheet showing them. of the subcontractors and their workers'cowry.policy infomrmtioa
I am an employer that is providing workers'compensation insurance for my employers. Below Is the policy and job site
Information.
Insurance Company Name: ��VL �Yv�j �i a 2� //v/
Policy#or Self-ins.Litz #: Expiration Date: /rl/
Job Site Address: rl& �"/rr�" y/-11— �cv ��%l City/State/Zip: ,(41f-7i 4e-// dlGn>6
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to serve coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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 die 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 certify r the paGrs and penalties ofperfury that the brformation provided above it true and correct.
Si lure: Da
Pbo s 'r
QQ'lcial use only. Do not write in this area,to be completed by city or town ofj4cid
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ijj1Vl AIR"vavaa -- -
� f
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. `
Pursuant to this statute, an emPloyee is defined as"...every person in the service of another under any contract of hire,
li ral or written."
express or implied,o
An employer is defined as an individual,parinersbip,association,corporation or other legal entity,or any two or More
of the foregoing engaged in a joint enterprise and including the legal representatives of a deceased employer,or the
receiver or trustee of an individ�,Partnership,association or other legal entity,employing employrxa However the
owner r a dwelling lease having not more than three and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on each dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be as employer.»
MGL chapter 152, §25C(6)also states that"every state or local licensing agency sham withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required.
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions 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 year situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. 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. Also be sure to sign and date the of idaviL 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 law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license Number on the to line
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact You regarding the applicant
Please be sure to frill in the pertnit/ticense number which wr71 be used as a reference number. in addition,an applicant
that most submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob Site Address"the applicant slbuld 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 filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ie, a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 wwwmm.gov/dia
a . CITY OF SALKMq MASSACHUSKTTS
PUSUC PncprL w D[IARTmom
' 120 WAaMINaMN 9PMM . 3aD FLMW
SALaM.MA OI 970
TaL (876)745-OSM [xT. 360
FA1t (970) 740-""
STANL6V A USOVIC=. JR.
MAYOR
DISPOSAL OF DMBIItS AMAVff
In meadows wi&the pommos dMM a 406 SX I aelmoavledp that u a condition
of Ba lft Pmmit 0 ,ao dsbria teeulti�fiom t6a eaoatelletioR
pvemed by db Boildhls Permit atoll be di pasd Otis a paopaly Hemmed solid•Maata
db*wd fmfts a defined by MM c HL SISOA. /
Tie dab&wi11 be dLpomd otak
Loggias of Facility
mil/ / Y/��`�✓ /�I��9S
$iBoature of Peewit Applieaot Date
FULLY goa�pleta t>r following inEormatioR:
(PL8A313 FRIIPI'CLBAItLY)
Neese o/�flPamir AppHcW
LrO
irm Name,if gay
Addruk City&Stag
The above statute r%mm that debris fiom the daoobbon.rmovatios6 rehab or other
altaation of bnildinp or gnicoene be disposed is a peapaly-Hmsed solid-wuw disposal
` f ciSty u defined by MGL ca Sl SOA, gad the bmWinS permits or Hcam an to
m ate the beation of the facility.