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HomeMy WebLinkAboutBLDG-19-002734 f, —}4 CSV ili wooMolsuMls@7algeAeds1un000e TVA] VIN 11301 9938-176E-809NVd �s , I 8LLL-176E1091131 P9930 dIZ VW 31V18 I H1nOWaVAH1noS Allo d�� roan N0Oatl3a8jSS3a00tl1 DNI1tl3H8DNI8Wn1dMO1SNIMdB 311tlNANtldW00 o ( #00111 I#0dIHSa3NldVdI 0l8Z61#DNOI1V80da00 01Ddl0der 0dr OdDW Ddi � -C 3an1VNDIS ' 86ZZ1 #3SN3311I Mo1SNIM'VN31-1d31S 3WVNa3uIdSVD-H38Wflld t7 elr" o "smel Iweueo NI p Zql ialdego pue apop Bul um ems spasn43mm; O e4110 uolslnad luewped Ile 411m GO O Wea vi eq Ulm uoileandde sit.{101 pans$!limed ell)Japun plumped suolleuelsul pue>p0M 6ulgwnld lie 1e41 pue (." e6pelmou>I 6w 30 lseq e4102 elwnaae p em1 we uopeopdde si416u1p>e6a>pe>elue JO pewwgns aney I uogeuuolul pue spelap 014 le Ila 1e41 Apse 6ge>eg I _4_ 1N30V 4-- 1N30V H0 a3NMO d0 321f11VNOIS ; • ❑ IN3DV 0113NMO :A1NO3NO NO3H3 ( \y'� �3 •luawannbai sly;SOAI¢M uolleolldde;Iwjad sly;uo am1eu6ls Aw ley;pue'mei IeJaua9 SRasny3esseL ay;Jo al,ialde43 Aq pannbai 06eJ0n03 aouemsul ay;any lou scop aasuaoq ay;Imp awe we I:213AIVM 33NVanSNI S,H3NM0 Q 0N08 0 AlINW30NI 3dAl H31110 Ej A3110d 33NVHflSNI A11118V11 M0139 X08 31VIUd0Hddtl 31410NI)103H3 A9 301/H303 d0 NM.31113IVOI0NI 3SV3ld'S3A 03)133H3 HOA dl I 0 ON I] S3A Zbl'y3'1DW to swawannbaJ NI spew yolyM lualenlnba IehueIsgns SI!JO Aallod aoue;nsul llllge9 wain a meg I 39VH3A03 33NV8f SNI I ai ±I �1 _Moat IMI � _= a31-110 _ UMW a a - an" H31V3H MOH 031N3ANn 1_0 ®11.11.1t a31V3H 1INn ��a IS31 llNn dol d00a ' lM _ I ® I ®, H31n3H 33VdSIMOH a31V3H 100d I ; 1 —11111 N3Ao �� IINn HIV dn3NVW J 8)1300 AHODHOEIV1 a31V3H 03atladNl 3111H9 S__ J _MIN __ a033VNHId �5� ,:���' 33VNand NM MN ��'�����E♦�� a01Vl0Aad �'® 30tl H3AHO ' a3Aa0 IM San* Nili 1=MS H31V3H 1N3A 103810 MISMIMIIIIIIIMISMIlan3AOISN000 ME MIS I;_ -'MI Nil=I a3Nan8 NOISa3AN03 Mal® _ _ 2131S00931S008 ---� J'l®— 1—. J 831108 14 , El 31. ll 6l 6 9 , 1 9 9 4 E a I, INN «-SHOO1d tS3ONVIlddV DON QS3A :03UI1AI81SSNtlld 1N31(33tl1d3d 0:NOIIVA0N3a D:M3N Arnwa1D INTISI _____©lVI1N301S321 0 lVNouvona3 Ervi0a3WW00 3dA1 AONW11000 gO aam. I Imi bLbIAbnlitia1I ALUM SS3a00tl2:13NM0 91 31 ,rI)fn S I1•l! I3WVNSa3NMO 4�n S PVosl lH .N fd"J 0� S3H]0tl311S901 #l11Na3d1 $II h U OI 131tl0 WI LI^n OW O Allo maw, 31210M ONlllld SVD W210d213d 01111A213d V 210A NOl1VOflddV W}IOdINf SI13Sf1HOVSSVW • ZSLA 1 I1.4 .+VII.II.VISM& SI II.MJ4.•YYI.11SJ46W _w Department of Industrial Accidents 'nit Office of Investigations _t �a' K, 600 Washington Street Boston,MA 02111 , t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name(Business/Organization/Individual). E•c.Wr n5i OW std x�ji r 1 1 • n c1 rl<arnq. `Ei111c. Address: 53" Qe�v, Ciao_ Q d City/State/Zip: Soon Yorw,c,,,(i., SA' Phone#: "505- 399..fl' 1 Are you an employer?Check the appropriate box: am a employer with 70 4. ❑ 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 :.0 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 ' 5. 0 We area corporation and its 9 ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance ret 4 ] employees.[No workers' comp.insurance required.] 13.0 Other my 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. tsurance Company Name: App,..) ('{u.4-j . .Pc n tt C qt,"R1✓ty olicy#or Self-ins.Lic.#: ) I3 a i pt �^ • Expiration Date: (—I — ;019tb Site Address:.23 1 km-e0-411 G.e3W4- NI City/State/Zip: egg b'7 • .[tach 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 MGL 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 ti.t a copy of this statement may be forwarded to the Office of tvestigations the DIA forinsurar-. overage yeti a',on. do hereby certify an • re ains a #penalties o p•jury that the information provided above is true and correct \�+ i_ at& � , IL_ Date: la 1 act. hone#: 'ct 3qy- 777Z Official use only. Do not write in this area,to be completed by city,or town official. • City orTown: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector \ Contact Person: Phone#: 1