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APPLICATION FOR
PEMWTO
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PBW� 'GRANTED
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3R0 FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. UEOvICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR 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 in, S 150 A.
The debris will be disposed of in:
(Location of Facility)
S �LEKI
Signature of Applicant
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigadons
600 Washington Street
Boston,MA 02111
www.massgov/dla
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Busicea�!0r�niratiwindividoal). Pm S
Address:LZ WZ L,`,(A ��n
City/Statemp: lTirOY��o�.c4�"t�,� 6 1 BA Phone
Are you an employer?Cheek thi4ppropriate box Type of project(required).
1.Cl I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub�-contracam;
R e •
2.�I am a sole proprietor or partner- listed on the attached sleet t � emod �g.
ship and have no employees These sub-contractors have S. ❑ Demolition
working;for me in any,capacity, workers' comp.insurance. 9, Q Building addition
[No workers'comp.insurance . 5. ❑ We are a corporation grid its,
required.)._
officers Lave exe5crsed thek 10.❑ Electrical repairs or additions
3.❑ I am a bomeowner.doing all work right ofexemptroii per MGL 11.❑Plumbing repairs or additions
myself. [No workers'.comp:, c. 152,If 1$1 and we have'ao 12.❑ Roof repans
insurance required,]t. �Ployeco [No workers'
comp.insurance igonea j 13.❑ Other
Any applicmt that cheeks box pl must also fill out9le section below showing they wnt" cote ad/on polity mfomtation:
t Homeowners who submit tha'effidavit mdketma they are doing all work and then lime otddde cowactors must submit a new affidavit indiem r,a sock
tContrectgta tlud deck this box must atmched in&I shed showing the nmm.oftbe sub-cou ctrns and tbea worker•am p.policy mfommeon.
Me
I am ap.'employer that is providing workers'eonWmadon htsuraecefor my eniploysia Below rs thepoliry and fob site
injormathxm.
Insurance Company Name:
Policy#or Self-ins.Lia #: Expiration Date:
Job Site Address: City/State ft:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Farilme 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 cerH r the pains and nakies ojperyury that the lnjormadon providedve abo /�'true and correct
SiArlatrre: DDoc: a '270 6
Phone#: 9-7 9 - N�g � R 9 73
Ofilci l we oils Do not write in this area,to be completed by efty or town oA*&L
City or Town: PerinklUcense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all emplOyers,to provide works' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every.person in the service of another under any contract of him - 4
express or implied,oral or writtea"
An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more
A the foregoing engaged . a. ..joint enterprise,and including the legal representatives of a deceased tmpbyer,or the
receive or trustee of an individual,partnership,association or other legal entity,employing employeta However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the'
dwelling(muse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(� o states that„every state or local licensing agency shall withhold the Issuance or
renewal of a Been"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 coverageh »d' shall
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its po '
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
ation affidavit completely,by checking the boxes that apply to your situation and,if
Please fill out the workers'compens
necessary,suPP1Y sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of
insurance: Limited Liabtlity'Companiea(LLC)or Limited Liabt'h'ty.Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC Or LLP does have
employ a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
ees,Accidents for confirmation of 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 ice ore is being if you try requested to obtnot ain D pertinent of
'Acci
Industrial policy,denta Should You have any questions regarding the l
lease call the Department at the number listed below. Self-insured companies should enter their
compensation p
nsurance license timber on the to fine
self-i
City or Town OfflciaV
Please be sure that the affidavit is complete and printed legibly. The Departrnent has provided a space at the bottom
of the affidavit for you to fill in the event the Office of Investigations has to contact You regarding the applicant
a reference number. In addition, an applicant
Please be sure to fill in the permit/license number in any givench will be year,
need only submit one affidavit indicating current
that must submit multiple permivlicense applications
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 die
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 citb=Is obtaining a license or permit not related,to any business or commercial venture
(ic, a dog license or perm it to bum leaves etc.)said person is NOT required to complete this affidavit
The office of Investigations would hike to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call,
The Departmeat's address,tcicpbone 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 5-26r05 www.mass.gov/dia