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'. The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /^ Please Print Legibly
Name (Bus iness/Organization/Individual):_. L C U-t T
Address: I y 9 (M A t J ST
City/State/Zip c bct eLV 41A O A 4 D Phone #: 9 - 743 5 Z3 4
Are you an employer? Check the appropriate box: Type of project(required):
J am.a employer with h, 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole or pro proprietor artner- listed on the attached sheet. t 7. ❑ Remodeling
P P
shipand
have no.em to ees These subcontractors have p y 8. ❑ Demolition
wofking for me in any capacity. workers' camp. insurance.
9. ❑ Building addition t
t;� No wor 5. W kers' comp, insurance ❑ e are a corporation and its
s. required.) - officers have exercised their 10.❑ Electrical repairs or additions
❑ 1 tun.vinomeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself:,tNo workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.) .t employees. [No workers' 13.❑ Other
—
I comp. insurance required,] —
•4r.y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
' Homeowners who submit this affidavit indicating they ere 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 showingthe name of the sub-contmotors and their workers'com .policy f o n ormation.
PP Y
I am an employer that is provlding workers'compensation Insurance for my employees. Below is the policy and job site
information. "
Insurance Company Name: � 1, M- . M �,' 4 \ _ _� ('� •�
Policy # or Self-ins. Lic. #: �+ Cn R "1 ���_ L7n F; Expiration Date: J `
Job Site Address: 3 O City/State/Zip: SA Le ers. MA C� 9—7 U
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
Fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fnc
of up to S250.00 a day against the violator. Be advised that 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 theep�pains and penalties of perjury that the information provided above is true and correct.
Sienature: L6,y1 V�Ce�� E Date:
Phone #: -2
Official use only. Do not write In this area, to be completed by city tor town official.
City or Town: Permjt/Vicense#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk_,,. Electrical Inspector 5, Plumbing Inspector
6. Other ark
Contact Person: Phone#:
k.
rnvrann varARTMIr .
120.WASHINGTON VMZST,aRD F6OOR
alAL,tM,MA 01970
TtL. (970)7434595 EXT.360
FAX (074) 740.96"
STAMXY J. U90V1CZ, JR•,
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisim of MGL c 40 S34,I acimowledge that as a coDdie..
of Building Permit 0 .all debris results fiom the consMwdm activity
govaned by this Banding Permit shaft be disposed of in a ploperiy ficeated soH&w.0
&Posal facility.as ddWed by MCiL c Iq SIM&
The debris will be disposed of at 4 o Y M n
Locadw of Facra t'y
Signature of Permit Applillews Date
FULLY complete the following iab'o® dM—
(PLEASE PRINT'CLEARLY)
Name o/f Permit Applicaet
Firm Name, if say
U ot MA l r�) S t-
Address, City A State
The above statute requires that debris from the demolition,reaovadon,rrhab or otbar
alteration of btuldiog or atructlae be disposed in a properly-licensed solid-waste disposal
fldHty as defined by MGL dU,S 130A, and the building permits or licenses sue to
indicate the location of the fw ity.