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72 WASHINGTON SQUARE EAST - BUILDING INSPECTION �, �f ���J� / � 4 � - - - - _ _ ,�..a -a 6 � �� -� �.._._�._._ ' �� � . . ,.s � �� � � M woa.M�oo.�w w /' idt+�.s w�S�� ��O N S'c, .�Q�1' �IUIoi1t01M�1 Y��NO� �� Y�-�'�� .' M�OMIO�t�'A110tl l�Ol�s PI«►�.a�it 1a �.�y� M� �p�ot D�ok 61Md' P�' �M��wl��T9� �� ��.� n(.i4T2 �.�i 1 .F ?iCd. �'bn(S� . w�,��art uor�r a corw.atnY To�vao oa�►rs w� To�r+�u��eu�owos: �� 7n. u�d�nip��d �l► �PP�' tor a a� w a+Yd �ooadlrw b �n. tow�wirp �g n �p�oMoWor� � ��� � ow�.r.wm. . 4 � . � g'�'���- Q3`�-R �+� O�' �w�[I� ..C�G? --1 u� r IY�i�1�� �w a � � . �mr«.a wan. . 1Mo1�� I�W� � ^'` '� ; �ddnss� Phoiw � �cfe2 �.,�a`� _ .��?t �f23- �� C� — v��w.p.vo..ae�rmr� �z,., „! � r ' �1�Y1 a M��► �`1 �ry r�a J��rMtii.lor law�!1�4� � 11�4i1�iY b Ir119� MIoi4 A � f'1 — �� o , �,�: r� A �,�� cS ��os� o �" ��� X '� v.. � ����� o�wr�•:' o�aw o�wowcTo� oo� � �) �C ll/C� Sbn� '� ��a2 �r+ r�e, rGT- •v ���� ,f� I� ` � o a2�1 � '� , . �dJlli-m10lNl' JU�P � it) I [ a . 1�� , �� � w ~ Y � � � • . . . � `� _� � �� , a �� � o : �i � � , � � � � �� � � � � r� s a� 9 � �^ � + . �. � . . .. ,. ' . ' • . �. ,..•..,� . . ' '�.• . � . � • ;f � � 77�e Commonwealth of Massachusetts. � { Department ojlndustrial Accidents Ofj'ice oflnvestigations � � ' 600 WashingTon Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance�davit: Bui�ders/Contractors/Electricians/Plumbers Apnlicant Information � Please Print Leeiblv � � � � Name (suanesslOrganizationnnaiviauat): / �m n��. - �,c7 e� �/� AddCeSs: ��5'��� (°c�u/L`F �u �2rn City/state/Zip: �a��sr1 . !N'ct , o�2°�b Phone#: �7� - Ya 3-�/�/ �—_ ,. . Are you an employer?CLeck thraP'propriate bor ; . , , Type otproject(reqnired): , 1.0 I am a employa wiil► � /J �`� 4. I am a general confraaor and I 6. ❑New consUuction employas(fitll and/or part-time).• have L'ved the sub=contracrois 2.❑ I am a sole proprietor or parmer- lisud on the attached sheet. = 7. ❑ Remodelmg sLip and Lave no employees TLese sub-contractors have 8. ❑ De�lition worlrmg;for me in anY�aPacitX• workers' comp. msurance. 9. [] Build'mg addition [No wrorkeis' comp.insurance 5. ❑ We.azc a coiporatioa�d i�' : . required.) ± ,,. , officers have exerc�sed their , TO:� Electrical repafrs or additions 3.❑ I am a homeownv.doing alt work ght of e�cempttun'per I�iGL' 11.� Plumbmg re�airs or additions ri myself. [Noworkets',comp: c. 152,§1(4),andwehave'uo .12.� Roofre,paus msurance requ'ved:J t. , employees. [No`workers' . 13.❑ Other comp.insurance requved:J'� , •My epplicmt thai checka box i/1 muet also 51j out tlie eectlon below ehowmg the'v,wmkera'c�enation policy ietommtion.'. t Homeowve�s afio w6�mt this etLdavit mdicffi'mg tLry ere doing all work md then h6e oufside contisMota inuat eublmt s mw affidavit mdiceting such � =Contracturs tbet efieck tfis boz'iwet attached en additionel shat showing the nmrc.bf'tbe sulicontiectors md thea wmke�s'mrtry:poficy mf'ormarioa I am a�employer that Lv providing workers'compensation insurnrice for my ein'ployefs Below lt the polky nnd Job stte injormation. Insurance Comparry Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Siu Addresa: �� �Q $��^ar I o ,v ��.1 �G�'I' . City/St2te/Zip: �!� �lB.n� Attach a copy otthe workera'compwsation pollcy declarsdon page(show�ng the poticy namber sad eapiration date). Failun to sa,ure coverage as required under Section 25A of MGL c. 152 can lead to the imposidon of cc�inal penalties of a fine up w$1,500.00 and/or ono-year imprisonment,as well as civ7 penatties in the fom►of a STOP WORK ORDER and a fine of up tn 5250.00 a day agamst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance caverage verificaaoa I do hereby certl under the palns ond penaldes ojperfury that the injormadon provided above!s true and correct SiP,�aturt: �C-n4 d��ti�/ l(1�K ec�ti Date' � " � 3 —C5 � Phone#: �� $ ' Z � 3— G�7�� OJj�cld use only. Do nd write In thls area,fo be completed by e6y oi towx o,�c1aL Cky or Town• p��/���p Issutng Authority(ctrcle one): 1.Board oi Heakh 2.Buildiug Depsrtmert 3.City/Town Clerl� 4.Electrical Inspector S.Plumbing Inspector 6.Other Coufact Person: Phone#: Information and Instructi�ns � M�sachus�tts Generall-a"'S chaP�152 requires all emploYers to Plovide workers' compensation for theu employces.` ; �tt Avsuant w this statute, an employee is defined as"...every person in the savice of another under any contract o Lae, express or implied,oral or written." , An e�nployer is de5nod as"an individual,P���P>association,co�poration or other legal entiry>oI � er,or thmore of the foregoing enga8ed�°a jomt enurprise,and'mcludinB the legal representatives of a deceased eers� Y receiver or irustee of an individual,P��b'P,association or other legal entity>emPloYmB emP�Yces. However the owner of a dwelling house having�t more than three apazunenis and who resides therein,or the occupant of thc`" dwelling house of another who emP��t�oo sLall�becaus of such employmeut be deemed to bedan emPloya." or on the�ounds or bu�ding app MGL cLapter 152, §25C(�also states ihat"every state or local licensing agency�6he c mhmonwealth for�any r renewal of a Itceose or permit to operste a business or to constrnet buildings applicant who hae uot Produced acceptable evtdence ot compliance with the insnrance coversge rMuired•" Additionally>MGL 'chapter 152:§25C('�states"Neither the commonwealth�r any of its political subdivisions shall enter into any contract for the performance of public work unp7 acceptable evidence of coa�liance with the insurance requirements of this chaPter have been presented Lo the contracting authoriry." _ , _ APPlicanis � . Please fill out the workers' comPensadon affidavit completely,by checking t1►e boxes that apply Lo yoat situation and,if necessary,supP$'sub-�°ntracLo�(s)name(s),address(es)and phone number(s)along with thea certificate(s)of insurance. Limited Liab�7ity Companies(LLC)or L'm�ited Liab�7ity PazmersLips(LLP)with no employees other than Uie members or pariners, are not required to cazry workers' compensation insurance: If an LLC or LI.P does have employees,a policy is required. Be advised ihat ihis affidavit may be submiued to the Departrnent of Indnstrisl p�idents for confumation of insurance coveraga Aiso be,sm'e to sigo sud date the afridavk. The affidavit sLonld be returned to flie city or town tLat the application for tLe permit oi license is being requested,not the Department of Indusvial Accidents. Should you have any questions regazding the law or if you aze requirod to obtain a workers' compensation P��Yc Please call the Department at ffie number lis;ed below. Self-msured'companies should enter their self-insivance license numberon the approPnau lma City or Town OfBdals Please be sure tLat ihe alTidant is comPleu and printed leAbly. The Departrnent has provided a space at the bo�m of the affidavit for you to fii1 out in the event ihe Office of Investigations has to contact you regazd'mg the apP Please be sure W ffi in ffie petmiUlicense numbu which will be used as a reference munber. In addidon, an applicant that must submit multiple permit/license aPPlications in any givea year;need only submit one affidavit indicating cun'ent policy information(if necessazy),and under"Job Siu Addresa"the applicant should wriu"all locations in (city or town)."A wpy of the affidavit that has been officially st�nped or marked by the city or town may be provided to the applicant as prnof 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 ci�zea is obm�m°B a license or petmit not related to any busmess or commercial veniure (i.e. a dog license or pe�mit to burn leaves etc.)said person is NOT required to complete this affidavit T'he Office of Investigations would lil�e to thank you in advance for youc cooperation and should you have any questions. please do mt hesitau to gve us a call. I T6e DepatmeaYs address,ulephone and fax numba: The Commonwealth of Massachusetts Departntent of Industrial Accidents O[5ce of InvestigatIons ; 600 Washington Street ' Bpston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia � � I: _ �,, ��_ ,..� �.�._ w.� ...�.� �__-�___� _ ------- ----- --�_�.__._ _.-T+.____ _ __-- -. , II __^____.-- -- _..._ _.._ �-_._�___ _ . _ _ __� ___ _ : _ _ -- -- - -- - - -- - _____w.______`____ ___ __.___� �._._ - ------__..�___.._� . ___.»__,___ =- __ ____.__ . _ _ _-_..._ ._,_ _. �--------=;�1 _._�.�___.�»___._.--._____r___�_. ___,�__�__ _� . _. _ _ ; , ; _----- --- --- � I i j , , ' :+' lil , , � , , . � �i � � , � ; � ! � � , � I � � � '� I � •,` I , i Z (Y -- tn i I I � i 0 O i ,,' � I� � � ¢ o '; ' il � `; ; 4 Q � � , � W ; + � � � I � � ~ � ` ` �' � , _ ' � z J E LL �y Z i: (I . z ti j � , ,' � � � � ; � ; � i M Jr �; .� �� � , � a � !� �� � � ' i � di s� � 1 �� �' � �, !�� i� �; � ��; j; � � � � � ; �� � � � � ,, i; � � ' � ;I , -� ._ - - : ; -=- � - . if _,�__--- . � x �5 T-� � -� u�� ' � �; , , ___ _ _ ___. _ _----- --�.--. .-_- --.-.---------.____________.__ .____. _.____ _�,_ . � � � �'' - ;� �� � � vr , i, -4.�-:0" � � �� ; � �, : � �� �i � � : , � O a � ; '° � (: �y ' '� N � r 1 ' ' != O �' � ' � �q O -_:., � �i � � 1- �v :.. i 1; I , f ,� � O ,... �� � � , � . _.. � ...'__' � . 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