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The CommonweaCth ofMassaehusetts_
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dla
Workers'Compensation Insurance Affidavit: Butilders/Contractors/Electiitlans/Plumbers
Amplicaut Information (fin /� Please Print Le 'bl
Name (Businessbr�nizatio»Q�ividuao. l` 1 Y 1 C1"a'l b A
Address: S W h t
City/State/Zip: Q CA Phone# - 0l— -3
Are you an employer?Cheek thrappropriate boa'
1.❑ Type of project(required):
I am a employer with 4'. ❑'1 am a general contractor and I
empbyees(till and/or part-time).* have liked the sob-contractors 6: ❑New consbuctioa
2.g I am a sole proprietor or partner- listed on do attached sheen t 7. ❑ Remodeling
ship and have no employees These sob-contractors live 8. Demolition
working;for me in any capacity, worked' comp.•. insurance. 9•, ❑. g
addition
[No workers' comp,insurance 5. ❑ We ate a corporation and its' ;
required.1-i officers have exe cued their 10.❑ Electrical repairs or additions
3.❑ I am a homoowner:doing all work right of exemption per MGi- 11.0 Plumbing repairs or addition
myself [No workcW.comp:. c. 152,§1W,and we have . 12,❑ Roof repairs
insurance regnvod:,I t. employees. [No workers' ;
comp.insurance ed 13.❑ other
.r
'Any applicant that checb box t l insist oleo full out tlK section below showing mert.,worl�np'wntpeuaetion policy infonntion;-
t Homeowners who submit do of &vit indicating flay ens dome all work and men hire outside lea must submit a new affidavit iedicatina such
tContraMon that check this boi nines tltsobd an d"onrsisset showing the nmtteof%*cub-oonfiegas asid mein wo,kea'camp•policy mforttsetioa
lam ap'employerthar is providing tvorkers'compensadon btaumxce for my ealployyees Below is thepolky and Job site
Inf ormatioa•
Insurance Company Name:
Policy#or Self-ins. Lic #: Expiration Date:
Job Site Address: City/Stateift:
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 S 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
1 do hereby cerdfy under the AdW penalties ofperlury that the information provided h trot and correct
Sign!_ hie: ao"'IS Date'
Phone#: 0
O,oTcbd um only. Do not wrke in this ens,to be completed by eLy or man*&&L
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityirown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to probe worksrs
' compensation for their employees.
Pursuant to this statute, an emPloyee is defined as"...every.person in the service Qf another under any contract of hire,
express or implied,oral or written."
An employer is defined:as"an individual,Partnership, association'corporation or other legal entity,or cub two=m
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,
receiver or trustee of an individual,partnership,association or other legal entity,employing emPk•Yem However floe
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the"
oonsnuction or repair week on such dwelling house
dwelling house of another who employs persons to do maintenance'
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
w
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings is 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 not any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
have been resented to the MwAcdng authority"
requirements of this chapter P
Applicants
workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
Please fill out the
necessary,supply sub- clor(s)name(s),address(es)and phone number(s)along with their catificate(s)of
insurance Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the
required to carry workers' compensation insurance. If an LLC or LLP does have
members or partners,are not
red Be advised that this affidavit may be submitted to the Department of Industrial
employees,a policy is requi
Accidents for confirmation re insurance coverage. Also be sure to sign and date the affidavit. 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
Indu
strial
Accidents, Should you have any questions regarding the law or if you are required to obtain a workers'
can the Deparmen
compensation,policy;Please t at the number*led below. Self-insured.companies should enter their
:
self-insurance license mtmber on the to Tina
city or Town Officials
rinted legibly. The Department has provided a space h the bottom
Please be sure that the affidavit is complete and p
of the affidavit for you 10 fin out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the perniWficeme number which will be used as a reference number. In addition,an 2PPlicaut
need only submit one affidavit indicating current
that must submit multiple permit/license applications in any givenyear,
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 officiary stamped or marked by the city or town maybe 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 citiMis obtaining a license or permit not related.to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to comp hxe 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 as a can:-
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 www.mass.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICi, JR. TELEPHONE: 978.745-9598 EXT. 380
NwroR FAX: 978-740-9846
Salem Building 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:
ko'
� � ( dr� S�
A ` P� (Location of Facility)
Signature of Applicant
2t
Date
.. 'a Bo.ra of Baiwia;Regslatto■s aed Standards,
} - HOME IMP1tOVEMENT CONTRACTOR
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CMS CONST
CARLOS SANTOSb`
157 WASHINGTONSTR i �,G,,,. . j�cw
GROVELAND,MA 018X r Adniaytnar
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l �liex�arivinooreo�lJi ./�aaoadEuoedb i
I y 4 BOARD 00 BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR I
4 Numher.'CS' 085905
t Birthda0e�OtI27/1970 'y
Ex 01/27P2007 Tr.no: 85905 `
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CARLOS HI SANTOS
I t57 WASHINGTON
GROVELAND, MA 01834 Administrator