600 Loring Ave - Sousa Signs - workers comp 1
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The Carr:rnotrwealtl: of Massachusetts
F Department oflndustr•ialAceidents
a I Congress Street,Suite 100
r Boston,MA 02114-2017
r www mass.gov/dia
«Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information- Please Print Legibly
Na1ne(Business/Organization/Individual): Sousa Signs, LLC
Address: 225 East Industrial Park Drive
City/State/Zip: Manchester, NH 03109 Phone#: 603-622-5067
Are you an employer?Check the appropriate box: Type of project(required):
1.®I am aemployer with 22 employees(full and/or part-time).* 7. ❑New construction
f 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
f any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]t
IO❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5.❑I am a general contractor and i have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.#
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other sign work
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 4l 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 anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Eastern Alliance
Policy#or Self-ins.Lic.#: 01-0000115899 Expiration Date: 4-10-24
.lob Site Address: 600 Loring Avenue City/State/zip: Salem, MA 01970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal'violation punishable by 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.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 of perjury that the information provided above is true and correct.
Jason Gagnon Digitally signed by Jason Gagnon
Si..gnature: Date:2023.10.19 11:14:42-04'00'
Date: 10-19-23
Phone#: 603-622-5067
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#:
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