AFFIDAVIT SALEM MA The Co oki e lth of Massachusetts
Departireent of Indusl-piaiAccidents
Lufayefte City Center
_ 2Avenue de La elite, Boston,ALU 02111-17"50
Workers' Compensation Insurance,* davit: Builders/-on -actors/Elect cians/Plu hers
AP Ucant Information Please Print Legibly
Narne (Business/Organizationllndivid€aag):SOUSA SIGNS L4 C
Address:225 EAST INDUSTRIAL PARK DMVIF. _v
City/State/Zip:MANCHESTER, NH 03109 Phone#:603-622-5067
Are you an employer? Check the appropriate papa: • T",e of project(required):
1 ® I am employer with 30 4. F1 I azm a general contractor and 1 6 EJ New const action
employees(full and/or part-time).* h9ve wed the sub-comtmctors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ® Remodeling
ship and have no employees Thes-sub-contract-)rs have 8. F1 Demolition
working for me in any capacity. eAl'l€:Yees and have workers' 9. ,0 Building addition
[No workers' comp. insurance comp.insurauce.�
5. We are a corporation:and its i0.[]Electrical repairs or additions
required.]
3.� I am a homeowner doing all work officers have exercised fii�eiA l LE] Plumbing repairs or additions
myself. [No workers' comp. ribht of exemption per:dl�aL 12 ®Roof repairs
insurance required_] t c,°152, l(4),and w kers'have 13. other 6 n sta l l sign
c�pioyees. [No workers'
comp.insurance required..] ,
*Any applicant that checks box#1 must also fIl out the section be'sow showing their workers'compensation policy information.
Homeowners who submit this affidavit indicatinb they are doing G,work and then hire outside coati ors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet shooing she name of the sub-contractors and state whether or not those entities have
employees. 1f the sub-contractors have employees,they must piovi&�:heir w0f1cers'comp.policy number.
I cam an employer that is providing workers'compe asation insurance;or Hazy employees. Below is the poficv and iob site
information.
Insurance Company Name:EASTERN ALLIANCE 1NSURANCE COMPANY
Policy#or Self-ins. Lie. #:01-0000115899 Expiration Bate:4110/2025
Job Site Address: �+ l(D tA UD Cit,;/State/Zip: (Cm,
Attach a copy of the workers' compensation policy declaration pane(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25.E of l G-L e. 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 WORD ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of thss statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hererell,as der the a'ns andpenaltiies of p ury that the in,orr�a ionprovided above is true Land correct.Simature C� -QrU _ Date:
Phone#: 603-622-5067
i
Of wW use only_ Do not write in this area,to be eompieted by -kp or town offciaL
City or Town: � Permit/11cense#
Issuing,Authority(check one): `
OBoard®f Health 20 Building Department 300ty/Town Ck-,rk Electrical Inspector 50Plumbing
Inspector 6.00ther -
Contact Person: Phone#:
Y�