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x APPLICATION FOR THE REPAIR.RENOVATION CONSTRUCTION
' �DEMOLIITON:iOR CIIANGE:OF USE OR OCCUPANCY:FOR ANY EXISTING
r s-STRUCTURE.,ORsBUILDING
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s ,i 3.0 COMPLETE THIS SECTipN FOR WORK IN EaI4t3Sli�G BUILDING$ ONLY
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y �' � Estimated Cost of.Projed S_i.�L_
t �` `Permit fes'i' Estkneted:Coit X s7/i1000tlReeidentialt_ e
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r An Addit(onal $5.00 Is added as an
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Make aura that aliflelds ars properly and legiby written to ayoid dWiiyslii processing
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underalgned does hereby appyfor aBuilding-Permit to:bulk!to the abov s
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» yr spebiflcatforie Signed under penalty of perjury "
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The Commonwealth of Massachusetts
Department of Industrial Accidents
,,p Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers Compensation Insura
nce Affid
avit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 17 /c—
Address:
City/State/Zip: 5�� /%/�' Phone
Are you 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(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. �• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition
o workers' comp. insurance 5. ❑ We are a corporation and its
re P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I 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.❑ Other do6F�
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: G / O / o J 2 s/-/ e/
Policy#or Self-ins. Lic. #: /0 Cl U W/ 9 Expiration
Job Site Address: City/State/Zip:_,�
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$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 $250.00 a day against the 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 under he pains and nal ' ofp u that the information provided above ' true a d correct
Si ature:
. Date: 1 b Q�/
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk. 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\L\u•M tx w.Ul ltk-..'ON Y aEM •SAU N,af.\:i\(:tu *1 1 s%9/.
Ttt:97L74S-9S" •F.%Y 9M74CM46
Construction Debris Disposat Affidavit
(required for all demolition auxl renovation work)
la accordance with the sixth edition of the State Building Code, 780 CNIR section 111.3
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 _ _ is issued with the condition that the debris resulting from
dis this work shall be posed of in a properly licensed waste disposal facility as defined by MGL c
1t1,4130A.
The debris will be transported by:
S.ale _�tet
(Ivama of hauler) ----�
me debris will be disposed of in :
h,ume ia:illty)
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