Workers Comp -Ves6
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2 Arvern we de Laf, etu're9 Boston,AM 02111 1-1 750
Workers' Compensation Insurance Afflidavita ��n����°�I�����°������/�������c�a�siP➢� ��r�
Applicant Information ease Prim Legibly
Name (Business/Organi2ation/Individual): j
Address: �' T
City/State/Zip: 7 Ph e#:
Are you an employer?Check the appropriate box. Type of project(required):
I.931 am a employer with . 9 4. 1 am a general contractor and I
employees (fill) and/or part-time).* have hired the sub-contractors 6 ❑New construction
2.® I am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers'
9. ®Building addition
[No workers' camp.insurance comp. insurance.* _
required.] S. We are a corporation and its 10.F1 Electrical repairs or additions
3111 1 am a homeowner doingall work officers have exercised their 11. Plumbing re❑ g pairs or additions
myself [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13. Other /`!
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 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.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensaFtion insams-m—e for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lin i� 0 �S,/, _ Expiration Date:�3
Job Site Address: _ J t ^ 4 CitylState/2-
_Z L
.Attach a copy of the workers' compen6tion policy declaration page(showing the policy number ana 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 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 DI ar nsurance coverage verification.
I do hereby certify un er th sins and penalties of perjaazy that the inform and onprovided abo a is true and correct
Si afore: 7,_
Date:
Phone#: Q �
Qf ficlal use only. Igo not write in this area,to be completer)by city or town official
City or Toww pern¢u��IIcense#
Issuing Authority(check one):
1EIRGard of Health 20 Building Department 3 0CntylTowu Clerk 4.0 Electrical Inspector 5 4umbing
Inspector 6.[Do Cher
Contact Person: .Phone#•