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authonu � { X r+ " {i io aetvn my behalf in n(1 matters.
�' reiaove to,Work euthoriaed by this bufldmgrpermitappl(cation r ;i r , '�° ''1 #�, I
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> _that the statements and mformatlon on the faregomg apphcat�on are foie and accurate'tv't�te b's[of my krmwledge and -
t beb9lf e r 6�(.t Y hrt t._`trry
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�-.�k aSignature'of Owtus^or Au Agem +.t ` ' e a p `zr. r-,�i y e a Date ,� ? f , n .� :•
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l rAn Ownerwho-vtilatre a bwlding perm to dv htslltu owmwvrk or M Droner who htrrs an unregistered cromrm for
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Cmi,regiefe in Hv�Improvement Contractor(HIC)Program) wtl(nvt .,ace to bte Drlatmutm R c
p ognun or guDYanty [xnder 1VI 6 P e6 t42a;Oth�Kmpm"WnInni mation an the HIC ogtwn aitd <, 4
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Constiction�3upavu or licensing(CSL�can ha found in 78D3CMIIt Regulations 11D R6 aiid 110 R5 respectivelytr
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
l Name (Business/Organization/Individual): e-l-r \y L pU/SE U4V/cs
Address: 4.�0/ LEE ST. ,
City/State/Zip: O/q�one #: 7P/ — 57V4—
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 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-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑Building addition
[No orkers' comp. insurance 5. El We are a corporation and its
Zr utre officers d.] ocers have exercised their 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' �/
comp. insurance required.] 13.(� t�therDEce REari
-Any applicant that checks box#] must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 and jab site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
mature: ✓ -Ozz L, - Date:
Phone#: 7 6- qYO — 33 7d'�
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): _
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: