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Department of Industrial Accidents
EMI
;�1l Office of Investigations .
?!La_ • 600 Washington Street
Boston,MA 02111
%.4,,,„—‘44 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
f Please Print Legibly
Name(Business/Organization/Individual): 6 .WtvsIo,,.0 QIU�b� aural •1
n `� t'1 r� Cel line.
Address: Ketvclev) Capt U
City/State/Zip: So.%iin Icrv'-'o to t4Pr Phone#: 'S38-3q9-vi'fl
Are you an employer?Check the appropriate box:
am a employer with 70 4. 0 I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
:.❑ 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. ❑Demolition
working for me in any capacity. workers'comp.insurance.
[No workers' comp.insurance ' S. 0 We area corporation and its 9 ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
• i.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no
insurance re 4 ]uired, t employees.[No workers'
12.❑OtheRoorepairs
comp.insurance required.] 13.0r
%ny 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 indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
isurance Company Name: TON.,..) (-Lk.A fines
olicy#or Self-ins.Lic.#: 'i$a t A
Expiration Date: C—[ — a019
)b Site Address:a3 Corvnin areal % Q COSI_ 1' NI
� 'ttF.�'1City/State/Zip: prey(o7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
ne 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
F up to$250.00 a da a ainst the violator. Be advised tt a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insura overage yen a on.
do hereby certify un • - penalties o/,p jury that the Information provided above is true and correct
I. atu •
Date: l a)?I I am
hone#: Si %Si• 727g .
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): 4.Electrical Inspector 5.Plumbing `
1.Board of Health 2.Building Department 3.City/Town Clerk Inspector \
6.Other
Contact Person:
Phone#: