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The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �//7• �i�cr U ��"tom
Address: r z?:W, woo
City/State/Zip: ��_ l Phone
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with_q 4. El 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. t 7• ❑ 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' i 5. El We are a corporation and its
re comp. insurance 10.❑ Electrical repairs or additions
required.] officers have exercised their
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.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other 06F�
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 sub-contractors 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 �J 7
Policy#or Self-ins. Lie. #: O U 4� `/� Expiration Date:
Job Site Address: City/State/Zip:__-52
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
Signature:
Date: U QG
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
\LNvr
12C WAS"' Ji:!7tEET•ULI.Nana::n.,L -Ili ,:9/
TV:v7E.745-1595 F.%x:9747449W
Construction Debris Disposaf ,affidavit
(required for all demolition atxl renovation work)
In accordance with the sixth edition of the State Building Code, 780 CA1R section 111.5
Debris, and the provisions of viGL a 40. S 54;
Building Permit 0 - , _ is issued with the condition that the debris resulting ffow
this work shall be disposed of in a properly licensed waste disposal facility as defined by �1GL c
111. S 130A
The debris wiII be transported by:
(na+aa of hauler) i
fhe debris will be disposed of in. :
'Xtl/ , ,�
W;W./ is iiity)
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