1 MARION RD - SIDING B-06-480 � .
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y The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
V11 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Leeibly
Name (Business/Organization/Individual):_ L �e C n„ , r T
Address: I `I 9 (lAt;�) S -r
City/State/Zip?_ a b�A O 1 q� Phone #: 9 —7 5 3 Z 3 4
Are you an employer? Check the appropriate box:
Type of
Type of project (required):
�i am a employer with J 5
4. ❑ I am a general contractor and I
employees (full and/or part-time).•
have hired the sub -contractors
6. construction
2. C1 am a sole proprietor orpartner-
listed on the attached sheet. t
7 ❑ Remodeling
ship and have no.employees
These sub -contractors have
8. ❑ Demolition
wotking for me in any capacity,
1; (No workers' comp. insurance
workers' cpmp. insurance.
5. ❑ We are a corporation and its
q. ❑ Building addition
' required.)
officers have exercised their
10.0 Electrical repairs or additions
3 ❑ I am.� homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
nryseif-jNo workers' comp.
c. 152, §1(4), and we have no
12.❑ Roof repairs
L Insurance required.j t
employees. (No workers'
13.❑ Other
comp, insurance required.]
—
.,I: Y app IQam mal MCOKs oox R l must also it 11 out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors must submit a new 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.
I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy andjob site
information,
Insurance Company Name:_
Policy # or Self -ins. Lia #: 6 bO R —1 :�l on 15; Expiration Date: � � � ` � C_
Job Site Address: / 0r) ti e7,i A -J Qsz, City/State/Zip:. 1A .v, 0 V
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 5250.00 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 certify under the pains and penalties ofperjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city, or town official.
Ciy or Town:
Permljt/pcense
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5 Plumbin Ins actor
6. Other
Contact Person:
Phone
tc.
• g P
• 120 WASHINOTON 9MM. 3RD FLOOR
SALEM, MA 01970
TEL (974) 74"595 UT. 360
FAx (974) 740-ge"
STANLEY J. U90VICZ, JR.,
MAYOR
DISPOSAL OF DEBRM AFmAVff
Iu accordance with the prOVWOnr of M($, a 40, S34, I aclmowle* that as a condition
of BmldiAg Permit S aU debris reaalting $om the conxaucdm
governed by this Building Permit dM be disposed of m a popaV Hcensed H& nab
disposal qty, as ddhW by MC$, c A S150A.
The debris will be disposed of at IP—F1 rc r,., t> 1 ",q (n Y MA.
LocatzM of Faulty
—_ 1-� Dom., (•.-i 1-�0 �
Srgaatnre Of Pezmit AppHdo
FULLY complete the foUawiag infoamadM-
(PLEASE PRINT C' MARLY)
C, h Ly Cutis �.
Name of POEMA ApplieW
/y
Name,
boa
Aftess, City A Stale
1 l :: - d
Dab
The above statute requires that debris from the demolition, rmovatiM rehab or other
alteration of banding or smican a be disposed is a properly -lick solid -waste disposal
facility as de5ned by MGL alL S 1 SOA, and the building permits or liceasa ars to
indicate the location of the iiadEV.