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The Commonwealth of Massachusetts
j h 6 Department of Industrial Accidents
4 11fV / Office of Investigations
/, 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A_ pplicant Information
Please Prmt Let=tbly
Name(Business/organization/individual):--A Q A Sp-r o a ,�•y�
Address: 11,5 1J o r+h Stre e+
City/State/Zip:_50J. 'im M►q 01970 Phone#:
F[No
u an employer?Check the appropriate box:
am a employer with a� 4. ❑ 1 am a general contractor and I Type of project(required):employees(full and/or part-time).• have hired the sub-contractors 6. ❑New constructionI am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
hip and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp,insurance.workers' comp. insurance 5. ❑ We are a corporation and its 9• ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no
employees. [No workers'
insurance required.] t 12.❑Roof repairs
,_,( V f7
comp.insurance required.) 13.NJ Other /
*Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
A
t Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
[Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name: t r e TrY(
Policy#or Self ins.Lic. #:_ X I a ti l n
Expiration Date:_ C) 1 1'.3) u7
Job Site Address: C'-1 y z P,f
City/State/Zip:�( ,fflm
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 STOP WORK ORDER and a fine
of tip 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.
do hereby cent! nder the pain
S and penalties ofperjury that the information provided above is true and correct.
Si nature:
Date: !-/ �' D
Phone#: N a H
=Other
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
I
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plum71nspector
son
Phone#:
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."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of 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 employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the rounds or build
ing appurtenant thereto shall n B g pp of because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"ever state or local licensing agency shall withhold the issuance
Y g g y or
renewal of a license 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 shall
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
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability 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
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate 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.
Please be sure to fill 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 future permits or licenses. A new affidavit must be 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 permit to burn 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 hesitate to 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
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M. G. L. c. 40, Sec. 54, a condition of
Building Permit Number is that the debris resulting from this work shall
be disposed of in a properly licensed facility as defined.by M. G. L. c. 111, Sec.
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Cartina -
Signature of Permit Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
I . 30ARDD 0 U p NG RE Tla 0 g t. License: CONSTRUCTION SUPERVISOR
INumbs r,'CS 057733
BI�I s1�pp��55_tt_2�_8g//.958
$� 4Os/26/200y Tr.no: 12633
Re 1
J
CHRISTOPHER
115 NORTH ST -
SALEM, MA 01970�
Commissioner ,I
I t
Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008
Type: Private CorporatIon
A&A SERVICES,INC
Christopher Zorzy
115 North Street ;
Salem,MA 01970 Ueputy AJminlatrator
Commonwealth of Massachusetts
Division of Occupational Safety
RoW J%zloso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Efl.Date 02J09/O6 .
Date ?/OBI07
DC 11 0
DC000440
Mwk rd C.O.N.E.S.T.
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DATE: - 9-0 7
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For: Location of Building
(Circle whichever applies) Roof,Reroof, Stall Sidin onstruct Deck, Sled,Pool
Addition Alteration epaidReplace, Foundation Only, Wrecking
Other. :t
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owned Name.—CA_ma ( 'gip/tY L/ Contractor: A � A orX
Street 8 m �( C o
__�.,�- a' . � Gn•"�� Streec� I4nr-Eh S�-. Cia� lam.
.State l-p Phone 078)1y 5 -3y State M A Phone, 078) ?J t:7, I o't H
Architect: City of Salem Lic# 1aD5
Street City State Lic 057 HIP 1< I D a O9
State Phone ( ) homeowners Exempt Form__yes_I,1 no
Structure: (please circl Single Fa rtu Multi Family# Other
_ ..
Estimated Cost of job$
Will building confirm t9 law? yes no
Asbestos?__yes_✓ no
Description of work to babe done:
.._L 2 5illI inr��fP�r� �l�I,� SCE-()a YP,S o VIn(L I S lr7/irk
A&A SERVICES, INC.
Drawin ubmitted:_des no Mail Permit to: 115
SALEM,MA 01970
% 'o`Zai741-0424. -
Signature of Ap lication,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Maput
Permit fee S
COMMENTS: ,.
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