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MEMO PEWIT APPLICATM POR:
Pwmk to:
(Ckole which ww apply) Roof pAwd IrmaY SWft W W" Deck, Shed, POOL
RpaidRaplsoa, Odw,
PLEASE IF"OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSM
TO THE INSPECTOR OF BUILDINGS:
The mWaiprod hereby appM for a pwmk to build aoowft tO ft blw"Q
Owners Name AJ�/✓1i1
Aftm& Phone `; 52 i l^ 913 f!i? ''>fct r
A d*ods Nano
Address & Phone j I
Medwnics Name J DI )Ugly 4 in), S�
Address & Phone 3z� Ce �na/ S . Sa.JJL,3 17�i 1a3 3- gla 5
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Ins lopmvmmt
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800D UNDER THE PENALTY
OF PBR�RY
DEsWc%aPTION OF WORK TO BE DONE 1 n(
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MAIL PERMIT
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77te Cotnmonwealtk ofMasswiluserrs
Department of Industrid Accidents
Offlm of Issmsdsadons.
600 Washington S&td
Boston,MA 02111
wtvwirnassgolMAW
Workers'Compensation Insurance Affidavit: BuHders/Contradors/Eleclease Print
Legibly
ApolicantIntormatio /�
Name
.T %) (�/o, ifr0
Address:
City/StatdLip: �
one# 7�
Ph
tit Cheek the appropriate loom Type of project(required):
Are r0i
;oy
4. [31 am a general contractor and I 6. New construction
oyer with _• have hired the sub-contracton
*U and/or part time). 7. ❑ Remodeling
Haw on the attached sheet _
a sole proprietor or parmet- There sub-contractols have S. ❑ Demolition
nd have ro employees wow, comp.i 9. ❑ Building addition
ng for me in any capacity. 5. ❑ We are a corporation and its
worker$' comp.it ursuce officers have exercised their 10.0 Elect ical repairs or additions
r«iairal rW of exemption per MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself [No workers' camp. c 152,)1(4h andhave no 12.❑ Roofrepaas
insurance ralnirod)t employees. [No ' 13.❑ Other
comp.insurance required.].
;Any&WHCsat tER chub box Nl vnt"fill
OW the seetim below eve dozen all ask and line oumde oonhsetofs vat almit We'�ihvit iota such
r Hmneuwnai wfio ruhmt flan affiarvic ink thnY
t�anwm"thud cheek*is box rout etWAa m 2&6600d sheet shownq the vine of the abcontrndas and tl�wmken'oon9.Policy iofamrlioa.
I aw as eaepbya that Is p►ovfdlnd workers'corrtpensadon Laurance jor sty employees. Below is the peaq srrdjob slue
Insurance Conroy Name n�r�ii�
Policy#or Self-fro.Lk Expiration Da
�0�/ Daft:Yen-Z �a�
/ t
Job Site Address: City/StaW7jp: J`��. ILIA, a 1970
or the workers' compensation policy declarados Page(showing the policy number and expiration date}
Attach
a copy to of a
Pahl=to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal Penalties
fine up to$1,500.00 and/or One-year iagnsomnent,as wen as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwxrded lo the Office of
Investigations of the DIA for insurance coverage verification.
I de herebyeeno under the and penalHa ojpcdwy than the Ltjo utadex pravi ed above b bur aril eorrreb
stananne
O,afcld use MI)t Duo Not%rise in thh area,to by compkAod by e1V or maw ealeld
City or Town: Pertnibucense M
Issuing Authority(circle one):
1.Board of Health L Building Department 3.Cky/Pown Clerk 4.Electrical Inspector S.Plumbing inspector
6.Other
Contact Person: Phone 0:
ZiliVl nla.e,aa,aVin NiiK ini►7 Fn naear biVllt7
Massachusetts General Laws chapter 152 requirer all employers to provide workers' compensation for their employrcL
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An empAPj o a defined as"an individual,parmership,association,corporation our other legal enft or any two or more
of the foregoing copgad in a joint entcprite,and including the legal representatives of a deceased employer,or the
receiver or.uhastee of an individual,partnership,association or other legal entity.employing employers. However the
owner of a dwelling house having not men than three apartments and who resides there*or the ocm pant of the
dwelling house of another who employs persons to do maintenance,coronuction or repair work on such dwelling home
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 15Z§25C(6)also state that"every state or local licensing agency shall wlthbold the hnanee or
renewal of a Ocease or permk to operate a business or to constrad buddlap in the commonwealth for my
applicant wise bas not produced acceptable evidence of compliam with the insurance coverage required.-
Additionally,MGL chapter 15$125CM states"Neither the commonwealth nor nay of its political subdivisions Shan
enter roan any contract for the perfomnance ofpublic work until acceptable evidence of compliance with the insurance
rapriremems of drier chapter have been presented to the contracting authority"
Applicants
Please fill out the workers'compensation af&IM completely,by chocking the boxes that apply b your situation and,if
necessary,supply tab-conVacsur(s)name(sl addresses)and phone number(s)along with then enstificale(s)of
insurance. Limited Liability Companies.(LI.C)or Limited Liability Partnerships(I I P)with no employees other than the
members or partner,are not requiral to carry worker' compensation ma iffsam If an LLC or LLP does have
eemployem a policy is required. Be advised that this affidavit may be submitted to the Department of Whasttial
Accidents for confnmation of insurance coverage. Also be sure to ship and date the affldavlt. The affidavit should
be returned to the city or Down 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 rquired to obtain a workers'
compensation,policy,please can the Depatmrat at the member listed below. Self tosured companies should cuter their
self-insurance licensemrmber on the apprt>priate line
City w Tower 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 fill in the permit/ficense number which wn71 be used as a reference member. In addition,an applicant
that must submit multiple permidlicense applications in any 1pven 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 ofBciany stumped orroarked by the city or town may be provided to the
applicant as proof that a valid affidavit is on Me fa fhAm permits or licenses. A new affidavit must be fined 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 licxoae or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The OtHa of Investigations would bite to thank you in advance fix your cooperation and should you have any questions,
please do not hesitater to give nee s can.
The Department's address,telephone and fax nsmber.
The Commonwealth of Massachusetts
Departmen of Industrial Accidents
office d Investigations
600 Washington ShVd
Boston,MA 02111
TeL #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-zt►OS wwrmass.gov/dia
i
.r
CITY OF SALEM9 MASSACHUSETTS
+ PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildine Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
�Q Mdall Z,,jZl e lr 7 (Location of Facility)
ignature of Applicant
/dZ
Date