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CITY OF SALEM
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BMLDNO PERW APPIJ M FOR.
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PLEASE PE.L OW LILY A COYPLETiLY TO Ava D D®.AVS N PROeag@Ip
TO THE I!WECTOR OF BWLDING&. '.
hemby aPPwr for a P mrk to build aawrd%to tfata f kmft
OwrrorsNrnr T E�/�: ��IZ�BE� � .
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600 WasUnaton Shed
Boston,MA 02111
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Workers'Compenandon Insurance Af1>davk: BVIMk slContndors/Electrkb=MImmben
Appfftsnt Int
Name �' (g,4R � /�G�fJIN
Atlt>rt:as: l 7
/1 A2 Cl1y —C 2
City/StatdZip: PryD61 PhoneaM:
Are yo■sm mpkW Cbeek the appropriate bmr Type or project(required):
1.❑ I an a mployer with 4. ❑ I m a pmaal etmascmr and q
employees(mn 20"r part-time o have hired the d, New Construction
2. 1 ma sole pmprittor of partner- listed on the attached skeet t A
ship aw baud no employeoa Tbne wb-mmm mra baud B. ❑ Demolition
[No worken,om*i-worm Ce 5. ❑ WWe an a oasporatin acid ib . 9 addition
regnked) ogkm bays exach d their 10,� 1*emirs or additions
I am a bomeownei doing an work right efesmpbim pa MGL 11. repairs or additions
mywx[No wmkas' comp. c. 15%11(41 and we have no 12 Roof repast
insmaaoe required.)t employees.Dim wodraa• 13.[]L-j Omer
camp•insurance rquired.)
;Any spPHe=t s,e ebeeke box rat mud att ooutaK uniex below A'ba trek vaeba'cotes o paw *nmdm
HomenMwm vbo mbmk NO SM&vk idkama rbey m donq A walk ad am bm Out"eoaRaaa I mum nbmk a ww o"vk tCoau.obn rw»Awk ft box not s b&W o Wad=W skeet ehoviq�.mmt otms sobeeateaAors eed�ar.w�k..•Coop
Ixj tArt b pro ir;wars'eonypsat is braunwto fp my e�rtpl�ns Bs/ew b A*PAVO and jo&A*
Iamaote Company Name:
Policy#or Se1Fms.Lic.N: Expaation Date
Job Site Addrar_Z2ZA%/3/C
Attach a copy of the workers'covaimsatlw ponq deetaratlon page(AMID@ the policy number and a phmdom date}
Failure to seam c waW as required under Section 25A of MGL a 152 can Ind to the hMosidm ofcrimiaat penaldea of a
tine up m Sl•500.00 and/or one-year imprisonment,as well as civil peuahip io the form of a STOP WORK ORDER and a lfae
of up to$250.00 a day against rile violator. Be advised that a Copy of this statement may be bmwded 10&C Otgm of
Imerugadooa of the DIA for iomrance ooverage vaiticubL
le barbyK a!pgdxw ores are bslsra d&np "Awebony b bw sadenraa
Phase Ap.-
O leid err m6t Do art wrirr b,A&are,as bo eoaVkmd bl eold'sr saws*skid
Cky or Tower: PwudtAUeme 0
fuel"Autborky(circle one)s
I.Board of Health 2.Building Department I Cky/rowa Clark 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Persom. Phone It
omm
Matsachusetm General Laws dapter 152 regal res an�r+Y�p�Pam wror of sty wntract of bias,
" in the aQVtte of anotherunder
pursnast to toes steam, an eaepriyw is defined as •-
•
apma
Ormolted,oral ofWOOL ir
_ _�,�,„,
as"era iadiv"parmm b* ° mt'oay pfa deceased anpioJer'of the
An eaWI*yw is defined se�•,W"^�__
oreeciver or tmtlea mom_'�'�'siciatcourpim a of owl �•er&aCis,err the o
__ o[tbe
owner of a dweltisg bouse"'I pema n do�tetaoe,O0n'�M*work as arch dwelling b0ow
dwelling�or�odwr w toercb sban notbeausa of and WWWmeatbe deemed a be a eraplayW*
MGL dapter 152,12SC•(6)abo antes twit"`va7 mu
or beat Memdog a62M sbd wft Y the h for O °a
rubgwat of a seem or permit to`p"rt`a budsess err to em±drt d �bWares"maw v»
alpaad wbe W soot Prod" weso
�`�``via of stars"Neit6a he o na MY Of ill politial subdlvuaa� shalt
Additionally,MGL chapter'eA I sC(7 t tbk taseoe of oomPliaeoc wi*the isar "w
pow moo any coussa$r the perms ofpabhewN a "Oft-
repircrocau of this lapses htrvebea presented
affidavit complete.by
cimwj fsg the boaea that apply to yam ustion and,if
secessmy,Supply+ub-o O) L� W with m ernpicyces other toes*e
iosmmum Limited Liabi ily OLL mwraooa If a LLC a LLY does bave
members or partners,are not requ><ad to tarry warhas be sad a the Deoartmat of�Ossoisl
empbyees,a policy u nquim& Be advised that this affidavit may
Accidents for caafirmatat of coverage: �a sure to dp aM date the affidavit. The sfllds<vit oho f d
be reuunad to the eitY or town that the M=y*V'an fbr the perm dw yr�dyoa are regeaed to a
Iodusuial Aoxtderts. Should you have sty quadana t�adlai
cocopeosatiasPolicY.please call the Departm�a1� lust°d�� SeH iosused eotopadies sbosld eats lbea
tins
self-, mace tl Zle namher on dw
C"or Tows MCI& rt the bottom
pkase be sure that tlu affidavit is complete and printed 1e>�4' The Depaunecachas provided a Space apP&=L
of the affidavit far yen 0 fin out m the event the Office of luvOOPttiom has a contact you tePtrddnf
>mmba which will be used as a reference tmmber• ht addition,as appitCat
please be sore a fiD is the perutitJticcme en year,need only submit one affidavit indicating turret'
that mist submit maltipk perrowbeense application in any Y licant ahonld write"all locations is (city or
policy but mataa(if necessary)and under"lob Site Adducer"the oar cily or teat may be provided to*0
to" "A copy of the affidavit tort bus boa oSltiaDY stsmPed marked s the ne
appliart as proof toes a valid affidavit is os fib for Subure permum of licere a. A new ai>;in for oxa filled out
year.wbere a toms owners dt citisa is obmbft a license or permit not related a spry business d oa>srmetclal
(i.e.a dog licem or➢fit a bwa leaves ere.)said pe m is NOT required to wmPltOe this at6davit
The Office of Investigations
world hie In luaus you in advance far yom cooperation and should you ban any Westiots,
please do not heumb to give us a CAL
The DMXUDeaCs at&as,telepbow and fu number:
The CommonweaUh of Massachusetts
Department of 1n&gnal Accidents
Ofam of Invess fpdonf
600 Washington Stied
BosM MA 02111
TeL #617-727-4900 ext 406 of 1-977-MASSAFE
Fax#
617-727-7749
Revised 5-2tI-OS www.111mgov/dia
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CITY OP SALSM9 MASSACHUSETTS
PUBLIC PROPOW DCPAWM[NT
i 1201Aa miftaMn STRZW,340 FLMN
aiAlw.MA of no
TEL (11761748.96" O[L 340
FAX (6761740-611"
STANL6V A Lkwm& JIL
MAVOA
DISPOSAL OP DBStIB AFPMVN
To mcordIwi wild the PWVWom ot?bdm a 44 3X I aelmmlwp that u a Gomm=
ot*Aft Palmit r .all Boat. t Pae the ooeateuedaa aeBviq►
Sa'umat bq hale Pamattt aW b,dLpoMd atita a pioparty licmed aolibwas
dkpoaal bdSts n dwwd by mm a nL U 3) & /�
Tb dd da wM bs&pond adat �X)0 ffh S>a� (��r}", n 4
Lace"ofiru ty
�Z 4 .
33"a of A m&"
FULLY am oft ft Mbwios mftmadoac
m"U PIMa cumm1n
Noma otPa�mit Appltaoi
File Nama�if aaq►
/9/ LaP._y-eke S�
Addrout City a$lilt
The above sum ra*nm that dAm he the damolbboe,ratovadM rehab of other
abtwsm otbuildtos or mucuue be dtgmW a a property-team W aolid.wum diVOW
hcTq m dadoad by M<'lI.cO,315" mad the Ml ft parmitt or lie--err of
n kalt do beadoo of t5e haft.