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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ulw� 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
/
Name (Business/Organ izationfindividual): L �„i t7 r C tyt r• T
Address: 19 M A t J ST
City/State/Zip br q Q i q� Phone #:
Are you an employer?Check the appropriate box: Type of project (required):
d;i�ll am.a employer with/— 4. ❑ I am a general contractor and I 6. New construction
employees (hill and/or part-time).+ have hired the sub-contractors
?.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' cgmp. insurance.
9. ❑ Building addition
[No s
[No workers' comp. insurance 5• ❑ We are a corporation and its
s. required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am.p.homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions
myseif [No workers' comp. c. 152, §1(4), and we have no
12.❑ Roof repairs
nsurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.] —
•4ny 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 are doing all work and then hire outside contractors must submit a new affidavit indicaing such.
Convactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. _
i am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: // M- . M t�� U 4 ('�
Policy # or Self-ins. Lic. # 3
II: b Q R 1 ����;� L7�7 S Expiration Date: H ` - ` C
Job Site Address: I Ll ,J-1 r T City/State/Zip: D 1 O
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 MGL 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 fine
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 weriftcation.
/ do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature� � 30-04
Date:
Phone #: �]
Official use only. Do not write In this area, to be completed by a city or town official.
r (+
Ciry or Town: Pertnjt/V icense#
Issuing Authority (circle one):
I. Board or Health 2. Building Department 3. City/Town Clerk_$,. Electrical Inspector 5. Plumbing Inspector
6. Other .,�.
s
Contact Person: Phone#:
x
..our. rnVri,RIT L/6rARTmgAT
120.WASNINOT0N a MlW. aRD FLOOR
SALZN.MA 01 Y70
TaL (970)745-9595 EXT.300
FAX (976) 740-Y6"
STANL EY J. USOVlcz, jp
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the proviaiom of M($,c 40,S34.I aclmawledr that as a cwAjd a
ofBmlding Permit 0 sR debris rwatmS Roan the owaucam sedyty
governed by this Bililding Permit shaft be disposed of is a properly licensed soBd-wuw
disposal facility.as ddbW by M(8,c M SIM&
The debris will be disposed of at 3
Location Of Famlity
Signalise of Permit Applicant Dab
FULLY comps de the following filftma>ion;
(PLEASE PRDM CLEARLY)
Name of ra=A"lica t
Ceti .
Fina Namq,if any
MA
Address,city&state
he above statute requires that debris from the demolidM rmvadMehab r or Other
sheration of building or smwtme be disposed in a Properly-hcensed solid-waste di
fa sposer!
cility as defined by MQ, WX SIS0A, sad the building permib or licenser arc to
indicate the location of the facility.