Untitled The
lei et Commonwealth of Maa,�'achrt,ce,t,
�e,: l nt'/rartmr�nt oJ'Indr►,ctrial Accidents
I' r:gre,s Street, Suite 100
' `= H°.�"tun. MA 021I4-2017
Workers'kern' www.rnas's.. ov/dia
Compensation Insurance Af[idavit Builders/Contractors/F,Icetricians/Plumbers.
l<�BE FILED WITH THE PF. u ilderiN(;A(ti'HOR1TY.
A !leant I ormahon
Name (Businesvprganization/Individual): +� Please Print 1,e ibl
jlt` l I')
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1�� C,, c^ J t�
City/State/Zip: / ' �(�{ of
— -- G? Phone#: 1 ^ G .)0 - C ,/ LI
Are yna as employer?Check the appropriate bo
1.0 —
am a engsloycr with employees(full and/or pan-tine)."
Type of project(required):
2.. 'aro a sDk proprietor or partnership and have no employees working for me in �' New construction
any capacity. [No workers'comp.insurance required.] 8. El Remodeling
3.❑i am a homeowner doing all work myself[No workers'comp"insurance required.]' 9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m ro I will 10 Q Building addition
Y P Pent
ensure that all contractors either have workers'compensation insurance or are sale l 1.O E cheap repairs or additions
proprietors with no employees.
❑ 12. • Plumbing repairs or additions
5_ lam a general contractor and I have hired the sub-contractors hated on the attached sheet. l 3.El Roof repairs
These sub-contractors have employees and have workers'comp.insurance t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other __-_
152,*1(4),and we have no employees [No workers'comp insurance required.]
*Any applicant that checks box al must also fill out the section belov:showing their workers'compensation policy information.
+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 rhKk this box must attached an additional sheet showing the name of the sub-contractors and state whether nr 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'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date.
�`‘ CT Si— i
Job Site Address: + Cit /State/Zip:.c..iC v'-'� MC.� J' �
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 toi$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 1-_--
do hereby cod un arms and penalties of perjury that the information provided above is wue and correct.
c
Date: • j • 2 C. O
Si nature:
Phone#: U
Official use only. Do not write in this area,to be completed by city or town official.
Permit/License# I
City or Town:_______
Issuing Authority(circle one):
d of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
I I. Boar
6. Other
i
Phone#: ____.------
Contact Person'