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APPLICATM FOR
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PEFPMTORANTED
w8P6 OF
` CITY OF SALEMO MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANL[V J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Buildine Deoartmejn
Debris DislWall 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.
T�qebris will be disposed of in:
�M (Location of Facility)
Signature of Applicant
Date
i
77ie Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
Aanlicant Information Please Print Lenibl
Name pasinesa/pr ization/Individual): �:` ' �1(�Li4� l f7
Address: 512 I OUCA,z r-P t
City/State/zip: �,hpM 4y - Phone M (003 o5�f VV(_o
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
empbyees(M and/or part-time).* have hived the sub-contractim; ,
2.❑ I am a sole proprietor or partner_ listed on the attached sheet t 7. emadelirtg
ship and have no employees These sub-contractors have 8. ❑ Demolition
worl®gz for me is any capacity, workers' comp. insurance. 9. Q Building addition
(No workers' comp.insurance 5. ❑ We ale a corporation add its ..
regWird.1_1 ii. officersLave ezeiclsed Their .❑10 Electrical repairs or additions
3.❑ I am a bomeowner.doing all work right of raern Ption per MGt 11.[} repairs or additionsmyself. [No workers~'.comp:. c. 152,41(4x and we have no 12. airs
insurance required`)t. cmploy6e [No workers' 13.❑ Other
comp.insurance tognred]
•Any applicant that cheeks box#1 must also fill out the section below showing thou worlum,motion policy mfomation; .
T Homeowners who submit this'affidsvit indicating they are doing all wort and then bire ioutada mnliectms uinst submit a new afdevit indicating such.
k-onusictors that check ibis box'must attached m adMomd shad showing the nmro of 6 sub-contiactors and the¢workers'ccmip:policy information.
I am an employer that is providing workets'eonspensadon hnurane2 for my eh ployttr+ Below is the poUry and job sh'e
injormatioa. I
Insurance Company Name: L I L12 F� AA
Policy#or Self-ins.Lic.#: WC Q3 Expiration Date: kZ In
Job Site Address: City/StatelZip: r 2�PM
Attach a copy of the workers'compens on 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 imprisonmen;as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerar y r the pains and penahin ofperfury that the!n ormaNin provided above k Nun and correct
Si tore: - -— -- Date:
Phone M (O-)J tP�d'
Official use only. Do not write in this area,to be completed by e4 or AMR o&kL
City or Town: Pe mean#
Issuing Authority(circle one):
1.Board of Health t.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employer$to Pro�4 workcas' compensation for their emploYep.' -
Pursuant to this statute, an employee is defined as"...every-person in the service 4f;another under any contract of hire,
express or implied oral or written"
An employer is defined-as an individual,partnership, association,corporation fir other legal entity,or any two or more
of the foregoing engage&in a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees However the
not more than three apartoients and who resides therein,or the occupant of
owner of a dwelling house having
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
t thereto shall not because of such employment be deemed to be an employer."
or on the grounds or building aPP�an
MGL chapter also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license
§25C(6)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 than
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 ,
'compensation affidavit completely,by checking the boxes that apply to your situation and,if
Please fill out the workers comp. es and hone mm�ber(s)along with their certificate(s)of
s address . P
sub-contracoor(s)°ame( � ( ) ees other than the
necessary,supply with no employees' Partnershipss ) emP
-lab (�
insurance Limited Liability Companies carry or Limited Liability _ lop
members orpolcypartners,are not required to cant 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
rance coverage. Also be sure to sign and date the affidavit. The affidavit should
Accidents for confirmation of insu is
ted,
ot
be returned to the city or town that the application for the pit or law or if beingou requesred n obthe Department worker of
IndustriaPAccidents, Should you have any questions regarding
coir�cnsationpolicy,Please can the Department at the number ljsted below. Self insured companies should index their
self-insurance license munber on the u lime.
City or Town Officials
Please be sure at the affidavit is complete and printed legibly. The Department has provided a space at the botto
th m
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 fin in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given 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 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 fbture permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizenis obtaining a license or permit not related.to any busiueas or'o mnmcial venture
(i.e. 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 besitate to give us a call:
The Department's address,telephone and fax numbs
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 www.mass.gov/dia