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4DCITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVIC=, JR. TELEPHONE: 978-743
MAYOR -9598 EXT. 360
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:
�k uc (Location of Facility)
,[-
Signature of Applicant
�—�
Date {
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Sheet
Boston,MA 02111
www mass gowwa
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridamffllumbers
Avylicant Information Please Print Legibly
Name (sosi ss Ot ni ation/Iroividaal)' �ISF-2-Z ' CX;7 7 / 1,.1p
Address: 9 n7 ! E—lep,
City/State/Zip: /f it 4q/V-4- Phone#
Are you an employer?Check thr appropriate box:'
Type of project(required):
1.❑ I am a employer with 4. ❑°I am a general contractor and I 6. 0 New construction
gull-byces(full and/or part-time).* have hired the sub contracbrg
2.E3 I am a sole proprietor or partner- listed on the attached sheet t 7. �emodelmg
ship and have no employees These sub-contractors have 8. ❑ Demolition
working,for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
[No workers' gip.insurance . 5. ❑ We area corporation sad its' 10.❑ Electrical airs or additions
required.]_] t:, officers have exorgisedthey
3.❑ I am a homeownea,doing all work right of exemption'per MGL' 11.❑Plumbing repairs or additions
myself.[No workeW.comp. c. 152,j1(41;sad we have no 12❑ Roof repairs
insurance required.,]t. employees. [No workers' , , 1 13.❑ Other
comp.insurance T6quhre4j
*Any applicant that checks box#1 n=also fill out dso"on below showing their,wotkm'convention policy infomstiow
t Homeowners who subsoil On SM&vit indicating they am doing all work and than bbi&faille eoomtora otiat subnGt a new affidavit indicetiag anch
tContractgrs that shack this box'imtat attached-®additional sheet showing the nwm.bf the sub-matragors aad the¢workem'cmw.policy mfonnmion.
I am iqt employer that is providing trorkers'conepematdon Insurance for my end rd'eem Below Is the popsy and fob site
information.
Insurance Company Name:
Policy#or Self-ins.Lia#: Expiration Date:
Job Site Address: City/StatuZip:
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 der hereby cerrifjr the and nandu o dury that the Injormatdon provided above Is hue and correct
Sitmatltre Li' %ice/ 77 Date
--a
Phone#: Z l 7
O,&Ial use a* Do not wrife lo this area,to be completed by eAy or town ojk d
City or Town: Permit/Lltxnse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cltyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
n employer is defined;as"an individual,partnership,association,corporation or other legal entity,or any two or more
A
A the foregoing engaged-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�lOYeer However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant el the
dwelling boost of another who employs persons to do maintenance,construction or repair work on such dwelling house
or building apportonant thereto shall not because of soeb employment be deemed to be an employer."
or on the grounds
ter 152,§25C(6)also states that"every state or local licensing agency shy c'om hold the
is uance r
MGL chap to construct buildings in
renewal of a llcemise or permit to operat
e a business or ,.
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 shall
enter into any contract for the perfomrance of public work until acceptable evidence of compliance with the insurance
ter have been presented to the contracting authority."
requirements of this chap
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to Your situation and,if
necessary,supply sub-contractors)namc(s�address(es)and phone number(s)along with
their
no employees other than the
insurance. Limited Liability
Companies(L LC)or Limited Liability Partnerships(LLP)
members or partners, are not required to carry workers'compensation insurance: If as LLC of LLP does have
employees,a policy is required Be advised that this affidavit may be submitted tD the Department of Industrial
be,sure to sip hould
Accidents for confirmation of insurance verage'for theAlso permit of license is being requested, not the Departmend date the affidavit- The affidavit t of
be returned to the city or town that the applicationfloe law or if you are required to obtain a workers'
IndustriahAccidems S>mukl you have any questions regarding
compensation policy;please call the Departrnent at the number listed below. Self-rosured companies should enter their
self-insurance liceuee number on the to line
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact You regarding the applicant
addition, app can
Please be sure to fin in the permit(license number which will be used a e affidavit indicating current
that most submit multiple permittlicense applications in any givenY need only submit n
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 officiaIly stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fixture permits or licenses. Anew affidavit mostbe filled out each
year.Where a home owner or citizen'is obtaining a license or permit not related:to any business or commercial venture
(i.e.a dog license or pe n it to burn leaves etc.)said person is NOT inquired tocomplete 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 tn give us a call.
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