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Home My WebLink AboutBLDG-18-001324 Al f12/7 . I wo3Molsulnya@oa19eAeds;un000e 11%1 1I VIN 1133 99Z8-176C-809 XVd I 8LLL-176S-8091311 1799ZOIdIZ VW 31V1S H1f101/421VAHINOS Allo I 310H10NOOHV3218 SS9HOOV MINNISON18Wf11dMOISNIMd3 •3111VNANVdWOO y^17 I ICI 0111 I#0dIHS213N12:1tld oLBZ£ #0NOIIVu0&Joo 01Od1 Odor 0 d 0d9W 0dll J �� _ ei 3af11VNOIS `� EnEn #203011 MO1SNIM'V N3Hd31S MANN 213111dSVo-2139NIMd I .c //'JJ r r-7011 .smel leJeueD ey{;o Zqi Jaldeg3 pue epos fiulgwnid eaeIS s�esnyoesseW: (— NI Jo uoislnwd;uauryad He yllm e311e 03 ul eq IIIM uoneopdde slg1 Jo;penssl;lwied eta napun pawioped suopepelsul pue 1poM 6ulgwnld pe Imo pue eSpelmowl Aw jo;sag eqi o;e;emnooe pue 1 we uopeopdde slyl 6ulple6eJ poJelua JO pa;liwgns my I uopeuuolul pue spe;ap atop lie Imo yyeo Agway I IN3OV 21O 2J3NMO JO 3Xf11VNDIS 0 ❑I1\139V ❑ 213NMO :A1NO MO)1O3HO luawannbaJ sly;sanleM uo!;eo!ldde;Jwaad sly;uo amleu6ls Ain WIll pue'mei leaauao suasny3esseW 0> oLn jo ZyI Laldeyo 6q pannbaJ OBeJOA03 a3uemsul eql any Lou scop easuaall eql win 012Me we 1:a3AIVM 3ONtlflSNI S,1:13NMO p 0 0O9 0 AlINA3ON13dAl H3HIO In AO1lOd 3ONtl2Jf1SNl A11119V11 MO139 X09 31VI8dO2IddV 3Hl ONINO3HO A9 39V213AOO JO 3dAI3H131VO10N13SV31d'S3A O3N33H0 HOA xi ❑ ON Q SMA Zbl'lO1OA Jo swawaJmbaa aql maw y3lyM lualenmba lelluelsgns SI!JO Aallod a3uemsul 1plgell lnoma a aim I 39Va3AO3 3ONV8f1SNI aan J - ®tiit ilit a3H1O 2131V3'2131VM III ®� a31tl3H WOOa O31N3ANfl1111111:11.1,1111111, i® 1131tl311 iiNn !SU IINn dOl doOa 1111 2131V3H 30VdS 1:131V31-11d O021 nal 11111®11111® SN IIINAai HaOm SSE ® � 5 2J31V8H a321tl21iNl 111111 aO33VN2Jfld O?JIV1OAHd 1111111111.111,0111,111.11111 uas an 3OV213A21O ®,®. iscli , s 2131V3H1N3A101:110 III II 113AOIS N000 2J3N21H9 NOIIS2J3 NOO - _ 1001111111111 I 2i31sOO8 2131109 vl EL g1 IL OL 6 9 L 9 9 17 E Z L ws9 —S2OO1d t S3ONVIlddV MON ❑SMA :031111N8fSSNVld 111:11LI3W3oVld9a 0:NOIIVAON3a ❑:M3N d'IZIVr7D �1V11N3OIS321 ©1VNO11V0fiaa ❑lv1Oa9wat0 tu.Aiy f1OO -godL “Llyh31 I 1Xvdl LL9QtiI plod -d15idl1 J)di>anC5 �js_aaatl 3NMb .9 I litt/Uf Ini 3AVNSa3NMOI aunt -Fs?JJ(I0O(y y Issaaa0V311980r h ./Oas/n #1JWa3d ni,M621131V0 VW I . poihJ9\ ALIO ? hr_ r5—fir, .� a uu ..vuo.w..r+ow....vJ,ra.wew..n..uc...0 _w= Department ofIndustrialAccidents •!!Y Office of Investigations 600 Washington Street Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers tpnlicant Information c Please Print Legibly \Tame(Business/Organization/Individual): a,C.%MIAS(O,N tC[1,,,s4'9 8. �{0.l, (' tib Int. kddress: Qeadw, Claes .ity/State/Zip: Sou Ytr'w,c,. to NA' Phone II: I)8-399-itfl Nrre you an employer?Check the appropriate box: Type of project(required): I am a employer with 20 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction U❑ I am a sole proprietor or partner- listed on the attached sheet.t' 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolitionworking for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions ^��\\ ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • ,meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: t' I t f 01.3 tkJ.{-1/0.-A ��f t n C.,_ C,m-_trey icy#or Self-ins.Lic.#: I$a I A- 1 n. . lol�j Expiration Date: i el — aoi9 'SiteAddress:3 ,rAon,vr•eeJ 1, AFQ/ Ccckl City/State/Zip: Oa LI(07 :ach a copy of the workers'compensation. policy declaration page(Showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 rp to$250.00 a da a:ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of estigations • the DIAfor insult, - overage vert;on. 9 hereby certify un • e sins a penalties ojury that the information provided above is true and correct matte• ,_ — / Date: 1a)3l I aoli me #: Stj4:3S`I r 7978 (� Official use only. Do not write in this area,to be completed by city,or town official • k • City or Town: Permit/License# • \ I 1.Bingar ofly 2.Buircle one): 1.Board of Health Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 5.Other Contact Person: • Phone#: \ k) v I